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Full text of "U.S. Navy Medicine Vol. 70, No. 3 March 1979"

VADM WUlard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM H.A. Sparks, MC, USN 

Deputy Surgeon General 



Director of Public Affairs 

ENS Richard A. Schmidt, USNR 



Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 
Nancy R. Keesee 



Contributing Editors 

Contributing Editor-in-Chief: CDR E.L. 
Taylor (MC); Aerospace Medicine: CAPT 
M.G. Webb (MC); Dental Corps: CAPT R.D. 
Uirey (DC); Education: LT R.E. Bubb (MSC) 
Fleet Support: LCDR J.D. Schweitzer (MSC) 
Gastroenterology: CAPT D.O. Castell (MC) 
Hospital Corps: HMCM H.A. Olszak; Legal. 
LCDR R.E. Broach (JAGC); Marine Corps 
CAPT D.R. Hauler (MC); Medical Service 
Corps: CAPT P.D. Nelson (MSC); Nephrol- 
ogy: CDR J.D. Wallin (MC); Nurse Corps: 
CAPT M.F. Hal! (NC); Occupational Medi- 
cine: CDR J.J. Bellanca (MC): Preventive 
Medicine: CAPT D.F. Hoeffler (MC); Re- 
search: CAPT J.P. Bloom (MC); Submarine 
Medicine: CAPT R.L. Sphar (MC) 



POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery, ft disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
meet of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The fallowing distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine. Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone: (Area Code 202) 254- 
4253. 254-4316. 254-4214: Aatovon 294-4253. 294-4316, 294- 
4214. Contributions from the field are welcome and will be 
published as space permits, subject to editing and possible 
abridgment. 

The issuance of this publication is approved in accordance 
with Department of the Navy Publications and Printing 
Regulations (NAVEXOS P-35). 



NAVMED P-5088 



U.S.NAVY 




Vol. 70, No. 3 
March 1979 



1 From the Surgeon General 



2 Department Rounds 
Submarine Doctor: From Dancer to Diver and Lots More . . . TEL- 
MED: Providing Health Care Information to the Community 

6 Notes and Announcements 

8 Instructions and Directives 

9 Independent Duty — Update 

Field Management of Male Urethritis 
LCDR R.R. Hooper, MC, USNR 
LCDR L.P. Watko, MSC, USN 



11 Scholars' Scuttlebutt 

Summer Clerkships in Undersea Medicine 
gram in Health Resources Management 



Supervisory Pro- 



12 Features 

Team Approach Proves Effective for Human Relations Develop- 
ment 

LT M.E, Celmer, MSC, USNR 
LTJGM.M. McCarthy, MSC, USNR 
LCDR D. Shepherd, MSC, USN 
LTF.R. Tittman, MSC, USN 

16 Preventive Family Psychiatry Overseas: Experience with a 
Parenting and Child Development Course 
LCDR R.J. Gemelli, MC, USN 

21 Professional 

Effects of Topically Applied Fluorides on Cavity Preparations 
LTR.E. McArthur, DC, USNR 

26 Nutrition: New Component in Patient Education 
LT W.L. Harrison, MSC, USN 

29 BUMED SITREP 

COVER: The USS Grayback (LPSS-574) is an amphibious transport 
submarine shown under way in the San Francisco Bay. Dr. Dembert, 
whose story begins on page 2, is the diving medical officer aboard the 
submarine. 



From the Surgeon General 



The Impaired Professional 



The Joint Commission on the 
Accreditation of Hospitals discusses 
survey findings with the Command 
and Staff of our Naval Hospitals at 
the conclusion of biannual accredi- 
tation visits. There is always a 
pointed reference on the part of the 
JCAH reviewers that the Command 
certifies the physicians and staff as 
physically capable of delivering ap- 
propriate health care. The Com- 
mand also certifies that the physi- 
cians and staff are emotionally ca- 
pable to perform necessary func- 
tions within the medical facility 
reviewed — that if any staff profes- 
sional suffers from alcoholism or 
drug dependency, they are under 
treatment. 

The former Director of the Na- 
tional Institute of Alcohol Abuse 
and Alcoholism, Dr. Morris E. 
Chafetz, has stated that the inci- 
dence of alcoholism among the 
nation's physicians was one of the 
highest of any professional group. 
In the past six years there has been 
a five-fold increase nationally in the 
number of physicians disciplined for 
alcoholism. This is due in part to the 
JCAH requirement that hospital 
administrations certify the physical 
and emotional stability of their 
staffs. It has also been recognized 




that it is both legally and morally 
incumbent upon professionals in the 
health care delivery system not to 
protect contemporaries or subordi- 
nates suffering from alcoholism, 
mental illness, or drug addiction. 
As a result, the number of identifi- 
cations of impaired professionals 
has increased. 

Our physicians, dentists, nurses, 
corpsmen, and other paraprofes- 
sionals within the medical com- 
munity must provide something 
more to patients than technical 
expertise in the often imprecise 
science of medicine. Feeling and 
empathy are very much a part of 
what we must give. It becomes 



difficult for the impaired profes- 
sional to provide the requisite emo- 
tional support for the patient when 
he is personally suffering emotion- 
ally from the ravages of alcoholism, 
mental illness, or drug abuse. 

I fully expect the commands and 
staffs of the Navy Medical Depart- 
ment to make every effort to assist 
the impaired professional, for the 
good of the patients as well as for 
the individual. By allowing these 
individuals to continue untreated, 
we are subjecting them to failure, 
frustration, and even death. 

By identifying impaired profes- 
sionals and referring them for 
appropriate therapy, we give them a 
chance to fully recover and return 
to normal living. It is incumbent 
upon all members of the Navy Med- 
ical Department, both officer and 
enlisted, to closely review their own 
lifestyle, particularly their drinking 
habits, and to introspectively deter- 
mine the possibility of becoming an 
impaired professional. 



A/ 



1 




W.P. ARENTZEN 

Vice Admiral, Medical CoTps 

United States Navy 



Volume 70, March 1979 



Department Rounds 



Submarine Doctor: From Dancer to 



Diver and Lots More 



Mark Dembert is not content with 
just the healing arts. 

Besides being the diving medical 
officer aboard the USS Grayhack, a 
diesel-powered submarine, he's an 
artist, singer, photographer, car- 
toonist, writer, researcher, poet, 
hard hat and scuba diver — and, yes, 
ballet dancer. 

The Altoona, Pa., native is also 
the only doctor today riding a Navy 
submarine "fulltime." 

"That's because Grayback has a 
contingent of special warfare div- 
ers, and I am their 'personal' diving 
physician," he explained in his 
clear baritone voice. 

"I also have 25 other jobs," he 
mused with a grin, "which results 
from being the only diving medical 
officer in the Western Pacific." 

Though it is not required, Dem- 
bert gives lectures in diving medi- 
cine to staff physicians at the Naval 
Regional Medical Center at Subic 
Bay and the Cubi Point Dispen- 
sary, and makes "house calls" on 
Grayback crewmembers' wives and 
children when he can. "I do it be- 
cause I enjoy it. It's part of medi- 
cine," said the bespectacled Navy 
Lieutenant. 

He added, ' ' If only 1 had the time , 
I'd look into going on some mis- 
sionary trips to the barrios around 
Subic Bay and offer my medical ser- 
vices." 

Dembert entered the medical 
world in 1971 at Jefferson Medical 



College in Philadelphia, Pa., after 
graduating from Bucknell Univer- 
sity with honors in biology. 

It was during his freshman year 
at Bucknell that Dembert bloomed 
in many directions. 

He began with art. 

"I started doing cartoons in high 
school for the Altoona High School 
newspaper. However, with college 
art courses at Bucknell, I began to 
experiment with new media," Dem- 
bert explained, "Pen-and-ink, 
pastels, charcoal, and water col- 
ors." 

He "discovered" his best medi- 
um is pen-and-ink and his inclina- 
tions are towards caricatures of 
medical professors which were pub- 
lished in the Bucknell newspaper, 
"with some notoriety," chuckled 
Dembert. 

He has also submitted his car- 
toons to the Philadelphia Inquirer, 
New Yorker, and Playboy. "Nothing 
was ever published though," said 
the son of Mr. and Mrs. Bernard 
and Estelle Dembert of Altoona, Pa. 
"But that didn't deter me. I plodded 
on and still do." 

Dembert carries a little sketch 
book and a miniature water color kit 
with him whenever he travels. 

In that busy freshman year, he 
began writing too, submitting 
poems and short stories to his 
college newspaper and other publi- 
cations, like New Yorker and Yan- 
kee magazines. 



Soon, he became editor of Buck- 
nelFs medical paper. "I turned it 
around so well that it was noted as 
best medical school newspaper in 
the country by the Student Ameri- 
can Medical Association," said 
Dembert, trying not to boast too 
much. 

His first claim to fame was when 
he wrote a lengthy article, "The Ef- 
fects of Marijuana on Brain Metabo- 
lism," based on two years of 
biological mice research at Buck- 
nell. 

Later, when he attended Jeffer- 
son Medical College, he co- au- 
thored another piece, which was 
published in the New England Jour- 
nal of Medicine. "It was, more or 
less, a tongue-in-cheek case study 
— more like a discovery — of Frisbee 
Fingers," he said. 

Dembert' s definition: The dilem- 
ma of persistent frisbee throwers 
. . . frisbee finger is seen as an 
abrasion of the middle finger of the 
throwing hand. 

"If there's such a thing as tennis 
elbow, then there must be a 
phenomenon which can be called 
frisbee finger, ' ' Dembert laughed. 

The loquacious Dembert elabo- 
rated, "That article really cata- 
pulted my friend, a doctor now, to 
national fame. There were about 50 
radio interviews, live TV interviews 
with NBC and CBS. It was described 
in all types of news magazines from 
Medical Ethics Journal to Good 



U.S. Navy Medicine 



Housekeeping . . . and a mountain 
of letters from people all over the 
country. It was crazy. 

"The biggest catch was when 
Esquire Magazine named me one of 
the winners of the 1976 Dubious 
Achievement Award for writing that 
article," said Dembert with a grin. 

In his college days, he also took 
up guitar playing and singing, 
learning on his own, performing for 
friends at parties and at school con- 
certs. His favorite songs are by 
Peter, Paul and Mary, and Simon 
and Garfunkel. 

Then he heard about undersea 
medicine, submarines and the div- 
ing program of the Navy. Dembert 
signed up and upon graduating in 
1975 was commissioned a lieu- 
tenant. After completing his intern- 
ship at the Naval Regional Medical 



Center Philadelphia, he began his 
six-month training at the Naval 
Undersea Medical Institute in New 
London, Conn., including training 
with helium-oxygen deep-sea diving 
rigs at Naval School of Diving and 
Salvage in Washington, D.C. 

After this training, Dembert was 
immediately assigned as medical 
research officer at the Naval Sub- 
marine Medical Research Labora- 
tory in New London, working on 
projects such as: submarine family 
psychiatry, "saturation" diving, the 
effects of "nitrogen narcosis" and 
diver performance, and a project 
evaluating hazardous diving and 
divers' health. From this work, 
Dembert authored several articles 
in the field of diving medicine. 

"I am always looking into re- 
search as a side pursuit," said the 




Dr. Dembert receives a patient in his small clinic aboard USS Grayback. 

Volume 70, March 1979 



bearded Dembert. 

Other side pursuits include ballet 
dancing and photography. 

He took up ballet dancing two 
years ago in Philadelphia "on a dare 
from a friend's wife who teaches 
ballet. She didn't think I would do 
it, but I went ahead and joined her 
class, taking my lessons with 40 
girls, whose ages ranged from 11 to 
14," Dembert recalled. 

Dembert describes ballet as 
"physical creativity at its best." 

In photography Dembert leans 
towards black and white portraits of 
"friends I have known in Philadel- 
phia and here in the Western Pa- 
cific." 

Why all this activity? "I enjoy 
life. I look at it as a series of adven- 
tures, one after another. I might 
change into something else again," 
he explained. 

"There's a good chance I might 
go into psychiatry someday, per- 
haps to combine psychiatry, with art 
as treatment." 

That's still future tense though. 
Dembert wants his full concentra- 
tion now on submarines and under- 
sea medicine. "The Navy is giving 
me a good basic education, away 
from academics. That's a good 
thing — I am learning more," said 
Dembert. 

"I enjoy the Navy," the 28-year- 
old bachelor continued, "for it's a 
challenge and adventure." 

"I'll probably stay in as long as I 
can travel and enjoy my job. When 
that ceases, then I'll go into another 
phase. ..." 

That's LT Mark L. Dembert, MC, 
— always looking for something 



-Story and photos by JOC Jesse B. Jose. 



TEL-MED: Providing Health Care 
Information to the Community 



All of us are aware of the current 
national emphasis on preventive 
medicine and the quest for im- 
proved methods to increase the 
health care awareness and medical 
knowledge of the public. 

A recognized leader in the Navy 
Medical Department's campaign to 
improve patient education, CDR 
J.R. Erie, MSC, USN, Command- 
ing Officer, Naval Hospital Quan- 
tico, has established the staff, 
organization, funding, and com- 
mand support needed for a success- 
ful Health Education Program 
(HEP). 

A segment of Quantico's HEP is 
the development and distribution of 
health care information (e.g., book- 
lets, brochures, posters, news- 
letters, newspaper articles, etc.). It 
is within the scope of this segment 
that Tel-Med became a reality. 

Tel-Med is in use at many civilian 
hospitals and clinics in the country. 
However, the significance of the 
program initiated at Quantico is 
threefold: 

1 . It is the first Tel-Med program 
purchased by a naval facility. 

2. It is the first Tel-Med program 
in the Commonwealth of Virginia. 

3. It is the first Tel-Med program 
jointly purchased and operated by a 
military and a civilian organization 
for the mutual benefit of both com- 
munities. 

While assessing the Command's 
requirements for health education, 
it was apparent that the need to pro- 
vide accurate, consistent telephone 
information for the public should be 
a high priority. An exorbitant 
amount of the clinic staff's time was 
spent in answering routine ques- 



tions over the telephone. Informa- 
tion given was often incomplete or 
inaccurate. Tel-Med appeared to be 
the answer. 

Since other facilities have shown 
interest in pursuing the establish- 
ment of a similar program, this 
article will describe the Tel-Med 
system and the steps involved in 
setting it up. 

Tel-Med. Tel-Med is a telephone 
information system consisting of a 
tape library of over 300 medical 
topics. The tapes, of two to seven 
minutes duration, are designed to 
increase the public's awareness of 
good health habits and increase 
their understanding and ability to 
recognize particular illnesses or 
injuries. 

The San Bernadino County Medi- 
cal Society originated the tape 
library in 1972, aided by grants 
from the American Medical Asso- 
ciation, the California Medical As- 
sociation and the United States 
Department of Health, Education 
and Welfare. Tel-Med is a non- 
profit tax-exempt organization. 

Production of the tapes is con- 
trolled by UCLA Hospital's physi- 
cians. There are six steps involved:* 

1. The initial script is written by 
a physician. 

2. A telephone journalist trans- 
lates each script into "telephone" 
English. 

3. The physician reviews the 
"simplified telephone" version. 

4. A team of physician specialists 
reviews each script. 

5. A lay panel evaluates each 
script. If, as a panel, they have 

* "Tel-Med," Tel-Med Inc., Cotton, Calif. 



more than one question, the script 
is rejected and a 42 member Medi- 
cal Examining Committee of the 
San Bernadino County Medical 
Society revises it for resubmission 
to the lay panel. 

6. A board of physicians chosen 
by the purchasing agency reviews 
and can revise the scripts to reflect 
local practice, if necessary. 

Teletrontx. The hardware de- 
signed to receive the calls is a semi- 
automatic, multichannel playback 
system manufactured and marketed 
by Teletronix Information Systems. 
The number of playback channels 
required is dependent on the popu- 
lation served. 

The system works in a simple 
fashion: the patient placed an 
anonymous call (not collect) to one 
central number and requests the 
operator to play the tape number 
desired. The operator plays the 
tape, and the call is automatically 
discontinued on conclusion of the 
message. 

Patients obtain the tape titles and 
numbers through printed brochures 
and other public advertisements, 

Quantico - Potomac Program. Ex- 
amination of the descriptive mate- 
rial provided by the sales represent- 
ative confirmed the opinion that 
Tel-Med would be effective in pro- 
viding health information to not 
only the military beneficiary popula- 
tion, but to the local civilian com- 
munity as well. Potomac Hospital in 
Woodb ridge, Va., agreed and the 
wheels were set in motion. 

Numerous meetings between the 
sales representatives and officials of 
both hospitals were held to resolve 
such issues as, where to locate the 



U.S. Navy Medicine 



hardware; whether to use an an- 
swering service, volunteers, or staff 
members; how many lines would be 
needed; how many tapes should be 
included in the initial library; and, 
what kind of arrangements for cost 
sharing should be made. Care was 
taken to identify all the "hidden 
costs," such as installation fees and 
the cost of brochures and publicity 
(see Chart). 

A tentative agreement for pur- 
chase was submitted to the Office of 
the Staff Judge Advocate and, after 
review and revision, signed by the 
Commanding Officer of Naval Hos- 
pital Quantico and the Administra- 
tor of Potomac Hospital. 

A board of physicians and other 
health professionals from both hos- 
pitals reviewed the scripts and 
selected 150 to be purchased with- 
out revision, but with some refer- 
ence information added. These 



tapes were then ordered, along with 
20 duplicate tapes on topics of high 
interest to be available for more 
than one caller. 

The manufacturers of both the 
tapes and the equipment sent 
checklists to the program manager 
to assist in the coordination of the 
purchase, installation and imple- 
mentation of the system. "Getting 
it all together" was analogous to 
preparing a seven-course meal and 
trying to put it all on the table at the 
right time. 

The opening ceremony was plan- 
ned to afford maximum publicity, 
with community and military lead- 
ers involved as much as possible. 
Packets for the press describing the 
system and press releases were 
prepared. 

When opening day finally arrived 
on 16 Oct 1978, high visibility was 
essential to make more people 



COST LIST 



Teletronlx 

Equipment 

Shipment of equipment 
Installation and personnel training 
Expenses for Tetetronix installer 

Telephone Company 

Installation of telephone cable 
Monthly telephone fee 

Tel-Med 

Original tapes 

Duplicate tapes (high usage topics) 

Tape shipment 

Program support fee (insurance, updating service, monthly newsletter) 

Personnel 

Operators (answering service, staff, or volunteers) 

Publicity 

Literature (newsletters, press packets, etc.) 
Brochures and posters 
Opening ceremony expenses 



aware of the system and thus utilize 
it. Brochures were printed and dis- 
tributed. Scouts and volunteer 
organizations participated in the 
distribution of the brochures. It was 
also helpful to have a local paper 
print the tape listing and numbers 
in advance of the opening. 

However, publicity must be main- 
tained for the continued success of 
the program. Television and radio 
public service announcements will 
be a source of publicity. Also, the 
telephone company may list the 
tape titles and numbers in the tele- 
phone book as a public service. 

The Naval Hospital and Potomac 
Hospital Tel-Med program has been 
enthusiastically received by the 
community. Almost 12,000 calls 
were received during the first seven 
weeks of operation. Plans have been 
made to monitor the use of the 
system, review the tapes, purchase 
additional tapes, and identify prob- 
lem areas. After one year of 
operation, the contract will be re- 
evaluated. 

Some of the advantages of Tel- 
Med are: 

1. It is free to the public. 

2. It is convenient (almost every- 
one has a telephone). 

3. It is always available. The 
Quantico-Potomac program is oper- 
ational 24 hours, seven days a week. 

4. The caller remains anony- 
mous. 

5. The information is consistent, 
concise, accurate, and periodically 
updated. 

6. The system will remain in 
operation regardless of changes in 
staff or administration. 

If anyone is interested in investi- 
gating the possibility of establishing 
their own Tel-Med system they are 
encouraged to contact the Educa- 
tion Officer at Quantico or Tel-Med 
Inc. of Colton, Calif. 

— Prepared by LCDR Donna L. Munro, 
NC, USN. Naval Hospital, Quantico, Va. 

22314. 



Volume 70, March 1979 



Notes & Announcements 



In memoriam . . . CAPT Oscar H. Fulcher, MC, USN 
(Ret.), former Navy surgeon, and founder of the 
neurosurgery department at Georgetown University 
Medical School, died 22 Dec 1978, at age 77. 

Born in Amherst County, Va., Dr. Fulcher re- 
ceived his B.A. degree from William and Mary Col- 
lege in 1922, and his M.D. at the University of Vir- 
ginia in 1926. He interned in Seattle, Wash., and 
was a fellow in surgery at the Mayo Clinic from 1928 
to 1933. During Dr. Fulcher' s Navy career, he ad- 
vanced to the rank of captain and for a time was 
stationed on Guadalcanal in the South Pacific. Dr. 
Fulcher joined the staff at Georgetown University in 
1946 after World War II service as a Navy surgeon. 
He founded the neurosurgery department the same 
year and was its chairman until 1964, when he be- 
came a clinical professor at the school. He continued 
to teach until his death. 

Dr. Fulcher was a member of the Medical Society 
of the District of Columbia, the American Medical 
Association, the Harvey Cushing Neurosurgical 
Society, the Philadelphia Neurosurgical Society (of 
which he was a past president and historian), and 
the Academy of Medicine of Washington. He held 
the Bronze Star and the Navy Commendation Medal. 



Continuing education for Navy nurses . . . The 

Naval Health Sciences Education and Training Com- 
mand will sponsor the following continuing educa- 
tion course for Navy nurses: 

Behavioral Concepts of the Acutely III Patient (18 contact hours) 
Bethesda, Md. 21-23 May 1979 

This workshop will enable the participants to increase skills in 
intervening in the behavior of patients and their families as a 
result of the disease process and the hospital environment. The 
program will include a brief review of crisis theory and interven- 
tion, communication skills in the nursing interview, and the role of 
the Nurse in dealing with the dying patient and his family. A por- 
tion of time will focus on the critical care nurse in crisis. 

The course is open to Nurse Corps officers not cur- 
rently assigned to an oversea billet. However, 
nurses assigned to Argentia, Newfoundland; Ber- 
muda; Guantanamo Bay, Cuba; Keflavik, Iceland; 
and Roosevelt Roads, Puerto Rico, who have served 
at least six months on active duty, may apply. The 



course is also open on a space-available basis to 
Nurse Corps officers of the inactive Reserve. 

Nurse Corps officers wishing to attend the course 
should apply to the Naval Health Sciences Education 
and Training Command (Code 7), National Naval 
Medical Center, Bethesda, Md. 20014, following 
procedures set forth in the BUMED Instruction 
4651.1 series. Applications should be submitted four 
to six weeks before the course begins. 



AFIP courses offered . . . The Armed Forces Insti- 
tute of Pathology will offer the following courses: 

Comparative Pathology 7-9 May 1979 

The course is for scientists interested in the comparative patho- 
logic aspects of disease in animals and man. It is specifically 
designed to bring attention to disease processes in animals in 
which a similar entity occurs in humans. Differences and similari- 
ties of lesions, as well as the biological behavior of specific 
entities, will be discussed. The pathologic entities presented will 
cover a wide variety of species including man, and will be com- 
pared by organ systems and to specific cause. This course will 
consist of lectures supported by illustrative material. 

Applicants should be members of the Medical, 
Dental, Veterinary, Nurse, Medical Service, and 
Biomedical Science Corps of the Armed Forces. 

Seminars in Diagnostic Radiology 7-11 May 1979 

These seminars are designed to offer radiology practitioners a 
summary of the most important morphological principles that 
underlie the evaluation of roentgenologic signs. Materials have 
been carefully chosen to achieve maximum radiologic-pathologic 
correlation in the elucidation of disturbed morphology as seen on 
roentgenograms. An added feature of the course will be an 
emphasis on radiologic study and evaluation in oncology, with 
particular stress on differential diagnosis and detection. 

Applicants should be members of the Medical 
Corps of the Armed Forces, other federal services, 
or civilians with specialty training radiology. 

19th Annual AFIP Lectures 14-18 May 1979 

This is a review and compilation of recent information in Anatomic 
Pathology (and clinical pathology methods as they apply to pathol- 
ogy) involving the various organs and body systems. The review 
will include common pitfalls in diagnosis, review of unusual cases, 
statistical data as appropriate, review of articles (published or to 
be published by staff members), and new histoehemical, bacterio- 



U.S. Navy Medicine 



logical, biochemical, immunological, and toxicological methods in 
the daily practice of pathology. These sessions will provide the 
practicing pathologist with a combined period of instruction and 
review, and with concepts in pathologic anatomy as interpreted by 
the AFIP staff. 

Applicants should be members of the Medical 
Corps of the Armed Forces or other federal services 
who are board eligible or certified in pathology. 

Applications from qualified civilian personnel will 
be considered on a space-available basis. 

Further information may be obtained by writing to 
the Director, Armed Forces Institute of Pathology, 
ATTN: AFIP/EDZ, Washington, D.C. 20306. 



Thoracic surgery residency positions . . . The first- 
year positions of a two-year program are available 
for July 1979 in thoracic surgery at the Naval Hos- 
pital, San Diego, Calif, and the Naval Hospital, 
Bethesda, Md. These are accredited programs and 
offer abroad spectrum of training. For further infor- 
mation call: CAPT B.L. Aaron (San Diego), Com- 
mercial (714) 233-2365, Autovon 727-3850, Ext. 2365 
or CAPT H.E. Ashworth (Bethesda), Commercial 
(202) 545-0074, Autovon 294-0074. 



Psychiatry residency programs . . . There are a 
limited number of positions still available in the 
psychiatry residency program at National Naval 
Medical Center, Bethesda, Md. and Naval Regional 
Medical Center Portsmouth, Va. These positions are 
at the GME-2 year level and open in the summer of 
1979. Applications are still being accepted. For 
further information contact: CAPT H. James T. 
Sears, MC, USN, Specialty Advisor for Psychiatry, 
NRMC Portsmouth, Va. 23708. Telephone (804) 397- 
6541, Ext. 404. 



For complete details, write to: Oliver H. Dabezies, 
Jr., M.D., F.A.C.S., Rm. 1538, Tulane Medical Cen- 
ter, 1430 Tulane Ave., New Orleans, La. 70112. 
Telephone (504) 525-9930. 



Scientific exhibit . . . The American Medical Asso- 
ciation (AMA) periodically recognizes outstanding 
scientific exhibits that are displayed at their annual 
conventions. The Navy exhibit "Running Injuries — 
Diagnosis and Management" presented in the 
orthopedic surgery section at the 1978 meeting in St. 
Louis, Mo., has earned the AMA's Billings Bronze 
Medal for those Navy Medical Department person- 
nel responsible for its preparation and presentation. 
Selection criteria considered in awarding the Billings 
Bronze Medal include the contribution to medicine, 
excellence of correlation of facts, and presentation. 
Recipients of the award are LCDR Wayne B. Lead- 
better (MSC), CAPT B.K. Slemmons (MC), LT T.R. 
Wagner (MC), and CAPT E.S. Hockstein (MSC), 
National Naval Medical Center, Bethesda, Md. and 
CAPT J.S. Cox (MC), Naval Hospital, Annapolis, 
Md. Production of the BUMED-sponsored exhibit 
was accomplished by the Illustrations and Exhibits 
Division, Naval Health Sciences Education and 
Training Command, Bethesda, Md. 



Erratum ... In USNavMed 70(1):20-21, Jan 1979, a 
list was published of new Medical Service Corps 
members and nominees of the American College of 
Hospital Administrators. Unfortunately, during the 
preparation of this article, the following individuals 
were inadvertently omitted: 

Members 

CDR George W. Baldauf, MSC, USN 

LCDR David L. Vosioh, MSC, USN 



New Orleans medical assembly . . . The 42nd annual 
New Orleans Graduate Medical Assembly will be 
held 27 April-1 May 1979 at the Fairmont, New 
Orleans, La. There will be a $200 registration fee for 
nonmember physicians and $100 fee for military 
personnel and registered nurses. No registration fee 
for students, residents, interns and fellows. 



Nominees 

CAPT James I. Myers, MSC, USN 
LCDR Ronald K. Green, MSC, USN 
LCDR Douglas Suttle, MSC, USN 
LCDR George A. Swales, MSC, USN 
LCDR Ronald F. Turco, MSC, USN 
LT Donald J. Lemmerman, MSC, USN 



Volume 70, March 1979 



Instructions and Directives 



Medical monitoring of flight personnel 

Under modern operational concepts, aviation activities are deploying to remote shore bases 
and to ships that do not normally have medical officers trained in aviation medicine. In these 
instances, routine medical care may be given by primary care physicians or highly trained 
advanced hospital corpsmen. 

The adverse effects of many self -pre scribed "over the counter" medications, as well as 
many drugs dispensed by prescription, have long been recognized as detrimental to flight 
safety. Other complications unique to flying are inherent in many disease entities and treat- 
ment regimens. 

It is necessary to ensure that all flight personnel engaged in flight operations are physically 
qualified. A commanding officer of a squadron or an officer in charge of an activity may relieve 
from flying duty any individual deemed physically unfit for such duty, upon the recommenda- 
tion of a medical officer (not restricted to a flight surgeon), in accordance with MANMED art. 
15-70, OPNAVINST3710.7J, and BUMEDINST 1520.24. The commanding officer or officer in 
charge may authorize resumption of flying duty on the recommendation of a flight surgeon, an 
aviation medical examiner (AME), or an aviation medical officer (AVMO). 

Scope of this instruction. The provisions of this instruction apply only to Medical Depart- 
ment personnel in those remote areas where the services of a flight surgeon, an AVME, or an 
AVMO are not available on a regular basis. 

Policy. The authority to issue a Grounding Notice (Aero-Medical), (NAVMED 6410/1), 
recommendation to a commanding officer or an officer in charge is expanded, within the scope 
of this instruction, to include the appropriate Medical Department representative on inde- 
pendent duty — i.e., the advanced hospital corpsman — in addition to the medical officer. 

The authority to issue a Clearance Notice (Aero-Medical), NAVMED 6410/2), prior to air- 
crew members' return to flight duty following grounding, is expanded, within the scope of this 
instruction, to include non-aviation-medicine-trained medical officers and other Medical De- 
partment personnel who meet the following criteria: NEC 8425 (advanced hospital corpsmen 
who have completed the basic or refresher course in aviation medicine at the San Diego or 
Portsmouth School of Health Sciences) or corpsmen trained as NEC 8406 (aerospace medicine 
technicians) or NEC 8409 (aerospace physiology technicians). In those instances where air- 
crew members are hospitalized or have been grounded for more than 10 days, they must be 
examined by a medical officer trained in aviation medicine prior to returning to duty involving 
flying. 

Procedure. In all cases where a non-aviation-medicine-trained medical officer or a Medical 
Department representative issues a Clearance Notice to a commanding officer or an officer in 
charge, message or verbal concurrence must be obtained from a flight surgeon, an AVME, or 
an AVMO before the aircrew member resumes duty involving flying. 

Under no circumstances will an aircrew member, while on medication, be issued a 
Clearance Notice without concurrence from a medical officer trained in aviation medicine. This 
concurrence will be accomplished in accordance with guidance provided by the appropriate 
aviation type commander medical officer or Marine aircraft wing medical officer. 

Action. The Naval Health Sciences Education and Training Command is directed to incor- 
porate basic aerospace medicine training into the curriculum for advanced hospital corpsmen 
and the refresher training provided prior to reporting to units with an aviation capability. This 
training shall encompass all aspects of aviation medicine and will not be restricted to heli- 
copter operations. 

The aviation type commander medical officers and Marine aircraft wing medical officers are 
directed to develop methods to assure that activity OIC's and appropriate medical officers and 
Medical Department representatives are briefed and knowledgeable in aviation medicine 
responsibilities prior to deployment. Of particular importance is establishment of channels of 
communication to facilitate concurrence prior to issue of a Clearance Notice recommending 
that aircrew personnel be returned to flying status. — BUMED Instruction 6410.5 of 8 Aug 
1978. 



U.S. Navy Medicine 



Independent Duty — Update 



Field Management of Male Urethritis 



LCDR R.R. Hooper, MC, USNR LCDR LP. Watko, MSC, USN 



This article is designed to review disease manage- 
ment for personnel working in isolated locations 
where laboratory facilities and referral capabilities 
are limited. It will be assumed that the Medical 
Department Representative (MDR) is capable of 
doing a Gram's stain and a urinalysis and has no 
ability to culture for N. gonorrhea. 

Urethritis is an inflammation in the urethra, 
usually evidenced by frequency of urination, burning 
on urination (dysuria), or a urethral discharge. 

When a patient comes to sick bay complaining of 
urethritis he should be asked if he has a discharge or 
"drip." Evidence of a discharge may be obtained by 
examining the shorts and the urethral opening. Have 
the patient strip the penis several times if no dis- 
charge is observed. When there is a discharge a 
specimen can be obtained by gently applying a 
microscope slide to some of the exudate at the end of 
the penis. If no discharge is evident a urethral speci- 
men should be obtained by either inserting a sterile 
bacteriological loop (4 mm diameter) or a calcium 
alginate swab into the opening of the penis to a dis- 
tance of 2-3 cm and rotating gently upon withdrawal. 
If using the loop, the collected material is combined 
with a drop of sterile water, mixed well on a clean 
glass microscope slide, and allowed to air-dry. If the 
swab is used, gently "roll" the material over the 
center of the microscope slide several times and air- 
dry. After gently heat fixing the air-dried specimen, 
perform the Gram's stain and observe under oil im- 
mersion magnification. The presence of gram-nega- 



From the Navy Environmental and Prevention Medicine Unit 
No. 5, Naval Station, Box 143, San Diego, Calif. 92136. 



tive intracellular diplococci virtually assures the 
MDR that the patient has gonorrhea. Sometimes 
gram-negative diplococci are only visualized extra- 
cellularly by Gram's stain. About 20% of these in- 
dividuals have gonorrhea. In this event the stain 
should be repeated and, if the same results occur, 
the person should be treated for gonorrhea. If the 
patient is not allergic to penicillin he should receive 
4.8 million units of penicillin intramuscularly divided 
into two injection sites and 1 gm of probenecid by 
mouth. In the event of penicillin allergy the treat- 
ment is spectinomycin 2 gm intramuscularly. 

If the Gram's stain is negative, but an average of 
more than four white blood cells (WBC's) are seen 
per high- power field, the patient is assumed to have 
nongonococcal urethritis (NGU). Nongonococcal 
urethritis, etiologically speaking, is a "waste bas- 
ket" diagnosis which may include: infection by viral, 
parasitic, or bacterial agents; and allergic and trau- 
matic irritation. However, it appears that the major- 
ity of NGU acquired in naval personnel is of an infec- 
tious nature and responds to tetracycline. The rec- 
omended course of treatment is 250 mg four times a 
day for at least ten days. Generally speaking, the 
longer the duration of treatment, the higher the cure 
rate and in some circumstances a 21 -day course may 
be necessary. An alternate treatment for NGU is 
sulfisoxazole, 1 gm four times daily for 21 days. 

When a patient who complains of urethritis has no 
evidence of urethral discharge and <4 WBC's were 
observed on the Gram's stain, a urinalysis should be 
performed. Ten cubic centimeters of voided urine is 
spun down in a centrifuge at 1500 rpm for ten min- 
utes. The urine specimen preferably should be 
obtained after the patient has not voided for a period 



Volume 70, March 1979 



of at least four to six hours, such as an early morning 
specimen. The supernatant is discarded and one 
drop of the sediment is placed onto a clean glass 
microscope slide, a cover slip is placed on the top, 
and examined under high dry magnification for the 
presence of WBC's. If on examination of at least five 
different fields, an average of more than ten WBC's 
are seen per field, the assumption can be made that 
the patient has NGU and tetracycline is the most ap- 
propriate treatment. When less than ten WBC's per 
high dry field are seen on the urine examination and 
symptoms continue, the urinalysis should be re- 
peated at a later date. No antibiotic treatment is 
indicated in this situation. 

When gonorrhea is diagnosed it is also necessary 
to interview the patient in order to locate and treat 
his sexual contacts. Blood should be obtained for a 
Rapid Plasma Reagin (RPR) test whenever a patient 
is seen with venereal disease. If spectinomycin is 
used because of allergy to penicillin, the MDR is 
obligated to repeat the RPR at monthly intervals for 
a period of three months. 



Three to seven days following the diagnosis of 
either gonorrhea or NGU the patient should be re- 
examined for evidence of urethral discharge. If no 
discharge is observed, the MDR can assume that the 
patient has been cured with the provision that a cul- 
ture be obtained at a future date, when resources are 
available. If the patient still has both a discharge and 
a positive Gram's stain he may have reacquired the 
infection or he may be a treatment failure. If reinfec- 
tion is suspected, penicillin is the treatment of 
choice. If treatment failure is a probability, then 
spectinomycin should be used. 

A final word of caution: The decisions and as- 
sumptions made in the preceding should only be 
used where culture facilities are not available and 
referral capability is not present. While a Gram's 
stain is usually a reliable method of diagnosis in 
male urethritis, it is not as sensitive as the urethral 
culture. Some individuals who are treated for NGU 
may in fact have undetected gonorrhea. The con- 
tinuation of symptoms in any patient is an indication 
for referral as soon as possible. 



DN Saves Choking Victim 



DN Cheryl R. Redmond was 
recently awarded a Flag lifesaving 
letter of commendation from RADM 
Robert L. Baker, MC, USN, Com- 
manding Officer, Naval Aerospace 
Regional Medical Center. The pre- 
sentation was made by CAPT 
Thomas W. McKean, DC, USN, 
Commanding Officer of the Naval 
Regional Dental Center, Pensacola, 
Fla. 

The commendation reads: "You 
are commended for your quick 
acting emergency treatment that 
resulted in the preservation of life. 

While dining in the Pensacola 
Naval Air Station Enlisted Dining 
Hall, you witnessed SN Julio Gerna, 
a member of this command sta- 
tioned at the Naval Aerospace and 
Regional Medical Center Branch 
Clinic, choking on a portion of food. 
Your quick assessment of the situa- 
tion and decisive action in adminis- 
tering the 'Heimlich Maneuver' to 
clear the victim's throat was directly 



responsible for saving his life." ject. The technique is easily 

The Heimlich Maneuver is ac- learned. If you are not already fa- 

cepted worldwide as the most effec- miliar with it, most emergency 

tive first aid method of clearing an rooms and first aid courses would 

obstructed throat of a foreign ob- be able to provide quick instruction. 




Left to right: SN Gem, DN Redmond, and CAPT McKean 



10 



U.S. Navy Medicine 



Scholars' Scuttlebutt 



Summer Clerkships in Undersea Medicine 

The Naval Submarine Medical Center (NSMC), 
Naval Submarine Medical Research Laboratory 
(NSMRL), and Naval Undersea Medicine Institute 
(NUMI), located at the Naval Submarine Base New 
London, Groton, Conn., offers a variety of clerkships 
providing training and experience in a broad range 
of activities related to Undersea Medicine. Undersea 
Medicine encompasses the fields of Submarine 
Medicine, Diving and Hyperbaric Medicine, and 
Radiation Health Protection. 

Clerkships at NSMC are primarily clinical in 
nature and involve working with the men of the sum- 
marine service and their dependents. All of the 
major specialties and several subspecialties are 
represented on the hospital staff. Both inpatient and 
outpatient care are provided. Clinical clerkships at 
NSMC may be combined with academic and 
practical training and experience provided by the 
various activities in the area. 

Clerkships at NSMRL provide an opportunity to 
participate in research in a wide variety of opera- 
tional medical areas ranging from closed atmosphere 
systems to computer assisted diagnosis. Research 
clerkships at NSMRL may also be combined with 
academic and practical training in Undersea Medi- 
cine. 

NUMI provides didactic training in the various 
aspects of Undersea Medicine and coordinates such 
practical experiences as submarine orientation, sub- 
marine escape training, hyperbaric chamber orienta- 
tion, and Navy SCUBA diving. The one-week course 
"Introduction to Undersea Medicine" is offered to 
individuals in clinical and research clerkships. In 
addition, special courses in Submarine Medicine, 
Diving Medicine, and Radiation Health can be ar- 
ranged. 

Groton, Connecticut is on the southern New Eng- 
land coast convenient to beaches, Mystic Seaport, 
and Mystic Sealife Aquarium. It is midway between 
Boston and New York City with convenient transpor- 
tation available. 

Additional information may be obtained from: 

Commanding Officer 
Naval Submarine Medical Center 
Naval Submarine Base New London 
Groton, Conn. 06340 

(203) 449-3261 



Commanding Officer 

Naval Submarine Medical Research Laboratory 

Naval Submarine Base New London 

Groton, Conn. 06340 

(203) 449-3263 

Officer in Charge 

Naval Undersea Medical Institute 

Naval Submarine Base New London 

Groton, Conn. 06340 

(203) 449-3260 



Supervisory Program in Health 
Resources Management 

A supervisory program in Health Resources Man- 
agement is now available for master and senior chief 
hospital corpsmen and dental technicians. 

A specific initiative of the Surgeon General has 
been to more fully utilize the talents of the master 
and senior chief hospital corpsmen and dental tech- 
nicians in management roles within the health care 
system. To better equip them for this, the Naval 
School of Health Sciences (NSHS), Bethesda, Md., 
has developed a four-week seminar program in 
Health Resources Management. This program is in- 
tended for and directed at preparing E-8/9's for 
roles often filled by junior Medical Service Corps 
officers. A maximum of 20 personnel can be accom- 
modated at each session. 

Individual medical centers will provide travel and 
per diem funding. The Naval Health Sciences Educa- 
tion and Training Command (HSETC) will provide 
housing. Student orders will be endorsed, "Govern- 
ment Housing Provided." Transportation from 
quarters to NSHS will be provided, messing will be 
the responsibility of each student; however, the 
mess at NNMC Bethesda will be available for noon 
meals during the week. 

All nominations should be submitted no later 
than: 15 March 1979 for course dates 15 April-ll 
May 1979 and 9 June 1979 for course dates 9 July-3 
Aug 1979. Nominations should be sent to Chief, 
Bureau of Medicine and Surgery (Code 25), Navy 
Department, Washington, D.C. 20372. Students will 
receive specific reporting instructions from HSETC 
upon acceptance. 

The course curriculum and NRMC nomination list 
may be seen in BUMED Notice 1510 of 22 Jan 1979. 



Volume 70, March 1979 



11 




PERSPECTIVES IN 
MANAGEMENT 




nnmc 



Tt 



m 



BLAKE * MOOTON 



MASLOW 






11 iDRUCKERjf] 



H TAYLOR 



GALBRAITH 




A SEMINAR 

IN CONTINUING 

EDUCATION 



12 



U.S. Navy Medicine 



Team Approach Proves Effective for 
Human Relations Development 



LT M.E. Celmer, MSC, USNR 
LTJG M.M. McCarthy, MSC, USNR 
LCDR D. Shepherd, MSC, USN 
LT F.R. Tittmann, MSC, USN 



For years, the study of human 
behavior in organizations has been 
of paramount importance to top 
management in its actions affecting 
corporate operation. Recently, the 
specialized discipline of Human 
Relations Development (HRD) has 
grown in response to the need for 
methods to augment employee per- 
formance and satisfaction. Tangible 
tools for management utilization 
(both military and civilian) have 
evolved from these studies both 
within and outside the health care 
industry. While most management 
specialists appear to agree that 
there is a necessity for an ongoing 
effort toward managerial HRD, 
differences do arise as to proce- 
dures for implementation. Foremost 
among these differences is whether 
to use in-house talent or to hire out- 
side consultants. The purpose of 
this article is to present the format 
used for an "in-house" managerial 
seminar. 

One Approach 

At the National Naval Medical 
Center, Bethesda, Md., four Medi- 
cal Service Corps officers received 
Command approval to attempt an 



initial step toward the implementa- 
tion of an HRD program "in- 
house." Investigation into current 
concepts in HRD had revealed a 
strong trend toward contracting out 
formal programs to commercial con- 
sultants for educating and re-edu- 
cating the various levels of manage- 
ment. Such attempts, however, can 
be extremely expensive and they 
overlook the real economy to be 
realized by tapping the resources of 
in-house consultants. Inasmuch as 
dwindling assets for continuing 
education are appropriately chan- 
neled toward patient care educa- 
tion, utilization of resources within 
the medical center produced a 
management seminar which was 
available to the majority of local 
managerial personnel. 

Format Selected 

Once a commitment to the pro- 
gram was established there were, 
several procedural questions which 
had to be resolved. Initially, it was 
necessary to determine the benefits 
of holding the seminar within the 
confines of the hospital as opposed 
to removing the participants from 
their daily environment and thereby 



"retreating" the group. It was 
decided to select a location external 
to the medical center and yet acces- 
sible to it in the event attendees had 
to return to their offices. A second 
consideration was to whom the 
seminar should be opened. Adopt- 
ing the rather uniformly accepted 
definition of "manager" as one who 
gets results through people, the 
organizers decided to invite all 
levels of the medical center's super- 
visors — from chief petty officers to 
the commanding officer. Civilian 
managers were also included. The 
question of choosing the material to 
be presented was resolved by 
having each team member select a 
relevant topic of personal prefer- 
ence, research it, and present it. 
The selected areas were time man- 
agement, managing your natural 
resources, and boring meetings. 
Additionally, it was decided to 
present a panel discussion focused 
toward superior/subordinate-super- 
visor/supervisee roles and expecta- 
tions. 



From the National Naval Medical Center, 
Bethesda, Md. 20014. 



Volume 70, March 1979 



ia 



Program Scope 

The concept of time as the man- 
ager's most valuable resource was 
explored in an attempt to develop 
new behavior patterns which are 
sensitive to "time wasters" and 
which promote sound time utiliza- 
tion. As pointed out in Managing 
Your Time by Engstrom and Mac- 
kenzie the most important basic 
requirements are to prioritize one's 
activities, complete them in accord- 
ance with their relevance to the 
organization, and to finish one task 
before starting another. Utilization 
of such tools as a time log was rec- 
ommended and participants were 
advised to conduct a realistic self- 
appraisal of their time utilization 
every 15 minutes for a week to de- 
termine just how their time was 
spent. From this they could deter- 
mine their effectiveness with rela- 
tion to the goals they had set. Mac- 
kenzie states in The Time Trap that 
working hard is not necessarily 
good time management — the ef- 
fectiveness of a manager, not his 
efficiency, determines his success. 

It was suggested that all man- 
agers create and use a formal "To 
Do" list. Such a plan allows one to 
organize his/her work day through 
setting priorities and following 
through — while blocking interrup- 
tions. The related benefits of han- 
dling paper once (or acting on a 
problem when you receive it), the 
utility of effective planning, and the 
negative consequences of procrasti- 
nation were detailed. The concept of 
delegating responsibilities was de- 
scribed as vital to managerial suc- 
cess, and yet was identified as prob- 
ably the most poorly effective of all 
tools. 

The topic of managing your 
natural resources was selected for 
this seminar because of its broad 
interpretation and application in the 



management arena. It was divided 
into two philosophical aspects: (A) 
managing yourself and (B) manag- 
ing the problem employee. Part (A), 
was the more philosophical of the 
two in that it dealt with the concepts 
of the achievement-effective man- 
ager, management identification, 
and interpersonal awareness. Each 
of these three was broken down into 
additional component parts to in- 
clude discussions on the manager's 
effectiveness, promotability, in- 
fluence within the organization, 
attainment of power, political wir- 
ing, self-presentation, managerial 
introspection, and more. The over- 
all intent of this section of managing 
your natural resources was to 
remind the participants that they, 
as managers, have a commitment to 
themselves, the organization and to 
their subordinates. The underlying 
premise was that one must be able 
to manage his own natural re- 
sources before he can hope to 
manage someone else's. The sug- 
gested way to accomplish this is 
through introspection and identifi- 
cation of one's effectiveness, 
achievement level, aspiration, and 
the modus operandi to reach his 
goals. 

Part (B) of the topic covered not 
only the philosophical but also the 
practical side of managing the 
problem employee. The discussion 
included a formula for the identifi- 
cation of causes, changes, and 
conflicts resulting in problem 
behaviors and detecting those 
causes and changes and their sub- 
sequent resolution. There were 
many possible steps in each of the 
three stages, too lengthy to be 
discussed here. The intent of this 
approach was to remind and refresh 
the participants in the need for con- 
fronting and dealing with problem 
employees in a timely and realistic 
manner while encouraging the em- 



ployee to understand that he or she 
has the responsibility to work out 
his or her own problems. The entire 
approach of managing ones natural 
resources stemmed from larger and 
broader seminars given by the well- 
known organizational psychologist, 
Mark Silber. Mark Silber gives 
management lectures annually at 
the American College of Hospital 
Administrators conventions as well 
as at numerous other management 
meetings and forums. The source of 
this topic was extrapolated from 
notes taken at Silber seminars. 

Meetings 

Any successful, nonboring meet- 
ing consists of adequate communi- 
cation, practical organization, and 
appropriate follow-through. The 
topic on boring meetings was 
presented in two parts. Part one re- 
viewed why most meetings are 
boring or nonproductive. Part two 
reviewed the practical management 
basics of chairing a good meeting. 
Subtopics consisted of types of 
meetings, purposes of meetings, 
alternatives to meetings, cost/bene- 
fits analysis, decision avoidance, 
roles of participants, group dynam- 
ics, and time management. 

Since middle managers spend up 
80% of their time at some sort of 
meeting, and boring meetings con- 
tribute to poor productivity and low 
morale, it was hoped that a review 
of the basic ingredients of success- 
ful meetings would be of value. 

Panel Discussion 

The theme for the afternoon 
panel discussion centered around 
working expectations: management 
and employee relationships. The 
panel was composed of five persons, 
both managers and employees. Two 
panel members represented the 



14 



U.S. Navy Medicine 






management perspective (RADM 
J.T. Horgan, Commanding Officer 
and Mr. L. Christy, Head. Laundry 
Services), and two panel members 
represented the employee perspec- 
tive (Mrs. Elizabeth Grace, RN and 
DTI Vee Redding). The fifth panel 
member, a physician, Chief of Ser- 
vice <CDR Brian McAlary), played a 
unique role on the panel and repre- 
sented both a management and an 
employee perspective. 

The central element which ema- 
nated from the issue of working ex- 
pectations was communication. This 
was the primary area of thought for 
the panel. Questions relating to the 
interwoven elements of authority/ 
responsibility, organizational mech- 
anisms for timely feedback, and 
organizational receptivity to crea- 
tive thought and ingenuity were 
asked of the panel. 

The success of the panel discus- 
sion was in the diversity of the panel 
members, i.e., that panel members 
were selected from varying levels in 
the organizational structure repre- 
senting civilian, military, officer, 
enlisted, manager and employee 
thoughts and viewpoints. And in the 
reception of the panel by the audi- 
ence. 

Panel discussions can have many 
formats and subsequent criticisms 
revolved around format. Attendees 
seemed to prefer a more open dis- 
cussion with more attendee inter- 
action, i.e., soliciting attendee 
questions after each question pre- 
sented to the panel. This particular 
format allowed us to bring to the 
attention of the audience a variety 
of viewpoints with regard to the 
complexities of management/em- 
ployee communications and expec- 
tations. 

Evaluation Mechanism 

It was decided at the outset that it 
would be prudent to objectively 



evaluate the net worth of the 
program from the participant's 
standpoint, as well as to provide the 
presenters with feedback on their 
lectures. Therefore, an evaluation 
tool was developed and response 
solicited at the conclusion of the 
seminar. Additionally, it was agreed 
that in view of the fact that several 
practical management tools had 
been provided, it would be interest- 
ing to procure a follow-up evalua- 
tion 45-60 days subsequent to the 
program to determine if any of the 
presented concepts had in fact been 
fruitful to those in attendance. In 
this way the team could determine 
what changes, if any, occurred in 
the participants' daily modus ope- 
randi because of their participation. 
The results of the first evaluation at 
the close of the seminar were en- 
lightening, with both positive input 
and poignant suggestions. It is 
hoped that the follow-up survey will 
also be encouraging. The responses 
indicated that the presented topics 
were pertinent to the participants' 
daily concerns and that the time 
spent in attendance was worth- 
while. 

The follow-up survey showed 
apathy on the part of the partici- 
pants in view of the fact that of the 
70 evaluations sent out, 10% were 
returned. Of the 10%, all were very 
supportive of future such programs. 

From the Top 

HRD has been shown to be neces- 
sary and valuable. The results of 
this program further indicate that it 
is desired by managers, and this 
experience proved that it does not 
have to be expensive. The success 
or failure of conducting an in-house 
seminar with internal assets will be 
a function of the effort and polish of 
the presenters and the captivated 
interest of the audience. Ultimately, 
however, the success of such an 



endeavor as just described will 
depend upon the degree of support 
from top management. All attempts 
to solicit enthusiasm from middle 
management will be ineffective 
without a firm commitment from the 
top echelons. Command support for 
this program was 100%. Both the 
commanding officer and director of 
administrative services made time 
to attend the entire program and 
their contributions were well re- 
ceived by the group. Furthermore, 
the attendees were representative 
of almost all the corps at the medi- 
cal center: Medical Service Corps, 
Medical Corps, Nurse Corps, Judge 
Advocate General Corps, as well as 
the chief petty officers and civilians. 
The body of knowledge in man- 
agement has become immense. It is 
incumbent upon the organization to 
maintain a managerial awareness of 
the state of the art. This is one 
method of accomplishing such a 
goal at low cost, using in-house re- 
sources to provide current manage- 
ment topics to all supervisory 
levels. 

Bibliography 

1. Georgopoulos BS, Mann FC: Supervi- 
sory and Administrative Behavior. People 
and Productivity by RA Sutermeister, Mc- 
Graw-Hill Inc, 1969. 

2. Strauss G, Sayles LR: Personnel: The 
Human Problems of Management. Prentice- 
Hall Inc, New Jersey, 1972. 

3. Yoder D: Personnel Management and 
Industrial Relations. Prentice- Hall Inc, New 
Jersey, 1970. 

4. Engstrom TW, Mackenzie RA: Man- 
aging Your Time. Zondervan, Grand Rapids, 
Mich., 1967. 

5. Mackenzie RA: The Time Trap. 
AMACOM, 1972. 

6. Silber M. Ph.D., Organizational Psy- 
chologist. Silber Associates, Ltd. 701 Lee 
Street, Des Plaines, III. 60016. 

7. Mackenzie RA: The Time Trap. 
AMACOM, 1972. 

8. Glaser R. Short J: Training in Indus- 
try. Industrial and Organizational Psychol- 
ogy. Gilmer, B. von Haller, McGraw-Hill Inc, 
1971. 



Volume 70, March 1979 



15 



Preventive Family Psychiatry Overseas; 
Experience with a Parenting and 
Child Development Course 



LCDR Ralph J. Gernelli, MC, USN 



As a career Navy psychiatrist 
trained in both child and adult 
psychiatry, I was eager to prac- 
tice family psychiatry when I arrived 
overseas for the first time in August 
1977 at U.S. Naval Regional Medi- 
cal Center, Guam. Being the only 
psychiatrist on Guam with a staff of 
one enlisted Navy psychiatric tech- 
nician and servicing a large naval 
community, a large Air Force base, 
and smaller Coast Guard, Marine, 
and Army installations, it came as 
no surprise that there was an im- 
mense demand for psychiatric ser- 
vices. 

Our two pediatricians at the 
Naval Regional Medical Center 
were eager to bring referring chil- 
dren, adolescents, and their fami- 
lies for psychiatric evaluation. Until 
this time, referrals for child evalua- 
tions were made to the local civilian 
hospital Child Guidance Clinic 
which functioned without the ser- 
vices of a child psychiatrist or child 
psychologist. Consequently, a 



From the Psychiatry Service, National 
Naval Medical Center, Bethesda, Md. 20014. 



"child behavioral clinic" was begun 
in which I was able to see several 
children and their parents for 
evaluations each week. Almost im- 
mediately, however, the several 
hours of available weekly appoint- 
ments that I could devote to child 
and adolescent psychiatric evalua- 
tions were filled. The wait for a 
"routine" appointment in the clinic 
became, at the least, one month. 

Not surprisingly, many children 
needed either short- or long-term 
psychotherapy with active parental 
involvement. Unable to provide 
other than minimal therapy time, I 
was given permission to provide 
clinical supervision to the civilian 
staff at the local hospital Child 
Guidance Clinic who were conduct- 
ing psychotherapy with those mili- 
tary families referred to them by 
me. My involvement with Guam's 
Child Guidance Clinic produced 
more requests for assistance in 
evaluating troubled Guamanian 
children and adolescents than I 
could possibly provide. 

After a few months of seeing 
children identified as needing psy- 
chiatric help, it became evident that 
many children were presented with 



psychopathology that could be 
closely linked to either faulty par- 
enting practices. Either that or the 
psychopathology could have been 
prevented if the child's parents had 
identified the early seeds of the 
problem and taken immediate "ap- 
propriate" action in their home. 
Many parents were young and in 
need of guidance in parenting they 
would ordinarily seek from their 
own parents or other close family 
members if they were back in the 
United States. It seemed evident 
that there was a need in our military 
community for a course dealing with 
child development, parenting tech- 
niques, and identifying and appro- 
priately responding to the early 
seeds of child psychopathology. I 
needed parents to help me in pre- 
venting and dealing with child 
psychopathology. I also felt that it 
would be useful to "show" myself 
to parents to help dispel some of the 
myths surrounding the military 
child psychiatrist. There were many 
children I had already seen for 
"emergency" evaluation where it 
was evident that the parents 
avoided coming in until a crisis 
erupted because of feelings of 



16 



U.S. Navy Medicine 



anxiety or embarrassment associ- 
ated with the thought of presenting 
their child or adolescent to a mili- 
tary psychiatrist. 

Planning for the Course 

Mention of a possible parenting 
course brought enthusiastic support 
from both our pediatric staff and the 
commanding officer. Consequently, 
an ambitious seven-week, one even- 
ing per week, "Parenting and 
General Issues of Child Develop- 
ment" series of seminars were 
planned (Table 1). Major concerns 
in planning the course were the 
length (Would people give up one 
evening per week for seven weeks?) 
and the content of each seminar. 
The content of the course could not 
be too "professional." This would 
tend to make parents feel that child- 
hood development was too complex 
and many might return home 
feeling less able to handle their own 
problems in their own style. The 
course would not be a success if it 
produced a fourfold increase in 
requests for child evaluations! On 
the other hand, the impression that 
raising children was not complex 
was not to be fostered either. The 
goal was to give parents some new 
and useful concepts to begin incor- 
porating together in their own style 
and respecting their unique cultural 
parenting heritage. Flexibility and 
reassessing concepts of child rear- 
ing were to be stressed instead of 
presenting the "right way of raising 
children." 

The course was well publicized 
through military communication 
channels. The schedule of seminars 
and a description of the objectives 
of the course were printed in the 
military community newspaper. 



TABLE 1 . General Issues of Parenting and Childhood Development 



Monday Evenings <7;30 PM - 9:00 PM) 

Naval Regional Medical Center Auditorium 

Presented by: LCDR Ralph Gemelli, MC, USIM 

Session No. Date Topic 

1 30 Jan 1 978 Parenthood and healthy and unhealthy 

reasons to have a child; changing roies 
of mother and father in the military 
family. Pregnancy, Birth, and the de- 
livery experience; some early "seeds" 
of child abuse. The role of Grand* 
parents. 

2 06 Feb 1 978 Infancy (Age Bi rth - 3 Years) and 

issues of mothering, fathering and 
modeling; speech development, the 
need to handle frustration, body con- 
trol development; Basic trust. 

3 1 3 Feb 1978 Early Childhood (Age 3 - 6 Years) and 

Rules of Discipline and Rules of Punish- 
ment; sexual identity; issues of lying, 
stealing, and masturbation; the im- 
portance of play. 

4 20 Feb 1 978 Late Childhood (Age 8-11 Years) and 

the need to learn, compete and com- 
pare; school failure, early drug use, and 
deliquency; sex education. 

5 27 Feb 1978 Early Adolescence (Age 12-15 Years) 

and Adolescent Rebellion, Sexuality, 
and Rejection of parents. 

6 06Mar1978 Late Adolescence (Age 15- 18 Years) 

and the need to become independent; 
drugs, sexual promiscuity, runaway, 
and emotional withdrawal. 

7 13 Mar 1978 Child Abuse: Causes, types of, recog- 

nition, and prevention. 



Volume 70, March 1979 



17 



People were encouraged to attend 
as many of the sessions as possible 
because basic themes of parenting 
and child development would be 
developed during the course of the 
seminars. Because we expected 
many parents would be unable to 
attend all the seminars or would 
select only those seminars dealing 
with their current child's age, the 
subject matter of each seminar was 
planned to stand on its own. 

The seminars were open to all 
active duty, retired single and mar- 
ried personnel and their dependent 
spouses, and all interested adults 
eligible for treatment at the Naval 
Regional Medical Center. Children 
and adolescents were not permitted 
to attend. It was decided not to 
formally invite civilian parents in 
the Guamanian community because 
it was not possible to predict how 
many would attend from our mili- 
tary community. Invitations were 
personally extended, however, to 
those civilians providing varied pro- 
fessional services to military and 
civilian children and adolescents on 
Guam. 

Response of Our Military 
Community 

The seven-week course was con- 
ducted on consecutive Monday 
evenings in the auditorium of the 
Naval Regional Medical Center. 
The format comprised a 45-minute 
presentation, a short coffee break, 
and a final 30-minute question, 
answer and discussion period. Each 
presentation, except the first, was 
aided by slides that outlined the 
evening's subject matter. 

To our delight, the turnout was 
excellent, more than exceeding our 
initial expectations. The average 
total attendance per evening for the 
seven-evening course was 177 
adults. Eighty-five adults attended 
the entire course. As noted in Table 
2, the highest turnout was for the 



TABLE 2. 


Attendance 


Seminar Total 


Seminar Total 


1 225 


5 155 


2 219 


6 110 


3 230 


7 115 


4 188 




Average Attendance: 177 





seminars on pregnancy, early in- 
fancy, and the seminar that dealt 
with the principles of discipline and 
proper methods of punishment 
(Table 3). These particular seminars 
were most popular probably be- 
cause of the large numbers of young 
childb earing- age parents in our 
military community. Interestingly, 
we expected a larger turnout for the 
two seminars dealing with adoles- 
cence and the last seminar on child 
abuse. The reasons for the lower 
attendance for these last three sem- 
inars were likely due to: (1) less 
parents in our military community 
having teenage children; (2) the ex- 
pected attrition for a course span- 
ning seven weeks; and (3) the 
nature of the subject matter. Many 
parents dealing with the adolescent 
issues and problems discussed in 
these seminars find it hard to hear 
about and therefore acknowledge 



TABLES. Rules of Punishment 



1. Explained before and end "appro- 
priately. ' ' 

2. Postponement . . . reasons for 

techniques 

3. Let punishment fit the "crime." 

4. Add on not take away. 

5. Apology after punishment. 

6. Once done — then forgotten. 



that these problems exist in their 
home, e.g., promiscuity, drug use, 
or school delinquency. In like 
manner, all parents, not only those 
abusing their children, find it hard 
to hear about child abuse especially 
in being reminded such abuse exists 
in their own military community. 

Civilian turnout was encouraging 
and averaged about 45 adults per 
seminar. Those invited civilian pro- 
fessionals who attended repre- 
sented Public Health and Social 
Services staff for the Government of 
Guam, Speech and Hearing Clinic 
staff, Child Protective Services 
staff, Vocational Rehabilitation 
staff, School Guidance Counselors 
and teachers, Juvenile Justice staff, 
University of Guam teaching staff, 
and the staff of the Child and Adult 
Mental Health Center at the local 
civilian hospital. 

Course Content 

The focus of the entire seven- 
week experience was to give par- 
ents, prospective parents, and peo- 
ple interested in promoting normal 
child development, practical and 
useful information in helping them 
be more effective parents and 
adults in enhancing the healthy 
development of children. The point 
of view emphasized in all discus- 
sions was that parents are given 
specific tasks of parenting at each 
stage in their child's growth. Each 
parental task is a result of and stim- 
ulated by specific age dependent 
tasks all children must master in 
order to develop normally. For ex- 
ample, in the third seminar dealing 
with the 3- to 6-year-old child, the 
child's age specific psychological 
and social tasks were discussed in 
how these tasks stimulated specific 
psychological and social tasks for 
their parents to master (Table 4). 

An important part of each semi- 
nar dealt with universal problems 
and issues pertinent to the specific 



18 



U.S. Navy Medicine 



TABLE 4. 
3-6 Yeans - Developmental Tasks 



Sexual Identity - final choice 

Conscience - becomes internal 

Language - symbolic growth 

Isolated - to social play 

Play - "Passive to Active" 
Anxiety mastered 



period of childhood being dis- 
cussed. These topics included dis- 
cussions about the common prob- 
lems of temper tantrums (Table 5), 
lying, cheating, stealing, food rejec- 
tion, sibling rivalry, drug and 
alcohol abuse, promiscuity, school 
failure and delinquency. Although 
practical suggestions were offered 
in dealing with these behaviors, the 
main focus was on discussing their 
different etiologies so that parents 
could recognize the cause of the 
particular problem. Hopefully then, 
by dealing directly with this cause, 
they would be better equipped to 
help the child abandon the deviant 
behavior. 

Issues such as the prevention of 
homosexuality, concern about the 
effect of exposure of children to 



adult homosexuals, teenage experi- 
mentation with marijuana, teenage 
sex education and sexual intimacy, 
nudity in the home, and the effect 
on children of the recent role rever- 
sal "revolution" among men and 
women were all topics engendering 
considerable interest as evidenced 
by some very lively discussion 
periods. 

In each seminar, more time could 
have been devoted to presenting 
and discussing practically every 
topic covered. It was an ambitious 
undertaking to adequately cover all 
that was listed in the seminar 
schedule. In each forty-five minute 
presentation, I often had to say very 
little about topics I wanted to say 
very much more about. However, I 
decided, in this my first experience 
with such a course, to cover many 
important issues even if only a short 
period of time could be devoted to 
each. Only after giving this course 
several times will I and other mili- 
tary psychiatrists learn what issues 
among the parents produce the 
most interest in different military 
communities, e.g., overseas, small 
installations in the United States, 
etc. Also, in larger military medical 
installations with a larger Psychia- 
try Service, a course such as this 
one could become a valuable guide 



TABLE 5. Temper Tantrums 



Noaudience No performance 

Label it Then "ignore" it 

Hold child No hurting allowed 

No destroying allowed 



1. Overstimulation . . . Very young child 

2. Anger against self . . . Discharge 

3. Anxiety Episode in "Phobic" Child 

4. Constant threats or inconsistent parenting 

5. Illness or retardation 



in determining what topics pro- 
duced the greatest interest. Such 
topics, for example, would then be 
dealt with in individually scheduled 
seminars, in a parent weekend 
workshop, etc. 

Goals of the Course 

An overseas assignment con- 
fronts each member of the military 
family with similar tasks. These in- 
clude the loss of leaving families, 
friends and the conveniences in the 
States; adapting to a new military 
community overseas; and having to 
enter and adjust to the foreign 
society that "surrounds" them. The 
challenge for military parents is a 
most difficult one. They must assist 
each other in order to optimally 
adjust to these new tasks and pres- 
sures. Simultaneously, they must 
help their children not only to deal 
with the inevitable problems and 
developmental anxieties that come 
with growing older, but also help 
them cope with the anxieties con- 
comitant with experiencing a for- 
eign culture. 

The principal goal of this course 
was to give parents traditional con- 
cepts of child rearing and develop- 
ment and not to present a "cook- 
book" for understanding and dis- 
ciplining their children. The more 
knowledge parents have about tra- 
ditional issues of child development 
and standard parenting techniques, 
the better able they will be in choos- 
ing their own unique style of being 
effective parents and in enhancing 
their child's development during 
their period overseas. 

Another goal of the course was to 
bring our parents together for a 
common experience involving fam- 
ily life. The course brought together 
parents who were dealing with chil- 
dren of the same age. Not only did 
this coming together foster a feeling 
of mutual support but it enabled 
parents to find out what help was 



Volume 70, March 1979 



19 



available to them in the military and 
foreign community. Parents learned 
how to assist other parents in ob- 
taining help. Our parents found out 
how to pursue a child psychiatric 
evaluation, and also by meeting 
many of the civilian professionals 
attending the course, found out 
about services available in the 
Guamanian community such as 
Speech and Hearing, Vocational 
Rehabilitation, Special Education, 
and the Child Protective Agency. 

Discussion 

The military psychiatrist has an 
increasingly difficult task in provid- 
ing clinical services to his military 
community. Because of the sheer 
volume of demands made on his 
time, it is difficult to redirect some 
of his time into activities of a pre- 
ventive nature. A course such as 
this is one solution to this problem. 
By educating people in identifying 
situations fostering the develop- 
ment of mental illness in their fam- 
ilies and offering methods of cor- 
recting these situations, he prac- 
tices preventive family psychiatry 
and taps into the emotional 
strengths that people will draw 
upon in attempting to decrease psy- 
chiatric illness in their military com- 
munity. 

Few military psychiatrists are 
conducting this type of course. One 
reason has been already mentioned, 
i.e., the psychiatrist in the military 
community has little if any "spare" 
time. However, I believe this to be a 
minor resistance in explaining why 
more parenting and child develop- 
ment courses are not being taught. 

The major resistance is that most 
of our military psychiatrists are 
adult trained and consequently 
many feel the child psychiatry 
portion of their training has not 
adequately prepared them to con- 
duct a course on parenting and child 
development. Most military adult 



psychiatry residencies do not pro- 
vide any experience for residents in 
being active participants in the 
planning and presenting of at least 
some portion of a parenting and 
child development course. This 
experience should be provided 
sometime during the later part of 
residency training and coordinated 
by our child trained military psy- 
chiatrists. However, even though 
current adult psychiatrists may not 
have the breadth of knowledge and 
clinical experience to draw upon 
that a child trained psychiatrist 
possesses, they nevertheless have 
had enough training in child devel- 
opment and child psychopathology 
to present such a course. One aid 
would be to enlist the contributions 
of military psychologists, pediatri- 
cians, and nurses in the planning 
and presenting of any parenting and 
child development course. 

In an effort to assist interested 
adults as well as child psychiatrists 
in conducting such a course, repro- 
ductions of the 60 slides prepared 
for this course can be made avail- 
able. The slides form an outline for 
the entire course and are expanded 
upon by a bibliography and descrip- 
tive syllabus. Any psychiatrist in- 
terested in the syllabus and associ- 
ated Kodachrome slides should 
write to me. I am presently pursuing 
the possibility of BUMED funding 
for the cost of the slides for our 
naval psychiatrists. 

I feel that the enthusiastic turnout 
we received in response to our 
course would undoubtedly be re- 
peated at other military installa- 
tions. The parents were interested 
in learning more about their chil- 
dren and becoming more effective, 
involved parents. They welcomed 
the opportunity to come together to 
discuss traditional issues such as 
the psychology of pregnancy, and 
methods of discipline, but were also 
eager to deal with contemporary 
concerns such as sexual identity 



confusion, homosexuality, and mar- 
ijuana. 

One of the first concepts taught 
all psychiatrists during their initial 
exposure to child psychiatry is that 
children do not seek help for their 
symptoms of emotional illness. The 
help must be sought by their par- 
ents and your therapeutic alliance is 
always with the parents. Our mili- 
tary dependent children and adoles- 
cents will never come together to 
write a letter to the Surgeon Gener- 
al asking for more mental health 
professionals to teach their parents 
how to be more effective in promot- 
ing their children's mental health 
and optimal development. Our 
children being abused emotionally, 
physically, and sexually suffer 
silently, or act out their rage at their 
parents by becoming our school 
failures, drug abusers, and run- 
aways. Much has been done in the 
military, especially in the Navy, to 
identify these children of abuse and 
help them and their parents. Many 
times the emotional scars are too 
ingrained and long periods of psy- 
chiatric and other professional treat- 
ment is needed with often very 
guarded prognosis for the eventual 
readjustment of these families into 
our military communities. We need 
to focus on early prevention and our 
military psychiatrists must take the 
lead in educating the members of 
our military communities in con- 
cepts of healthy child development 
and effective parenting. 

Our course was given at a fairly 
isolated duty station with a high 
proportion of dependents, especial- 
ly children. And although an over- 
seas community would probably be 
viewed as a fertile environment for 
a course that helps parents cope 
better with their child's behavior, it 
is important to stress that our larger 
medical centers in all branches of 
military service serve populations 
that are also in need of courses in 
parenting and child development. 



20 



U.S. Navy Medicine 



Professional 



Effects of Topically Applied Fluorides 

on Cavity Preparations 



IT Robert E. McArthur, DC, USNR 



This paper explores through a literature review 
the extended uses of topical fluorides in the field of 
dentistry. The validity of maintaining an effective 
concentration of fluoride in water (1.0 - 1.2 ppm) to 
reduce tooth decay has been well documented with 
studies completed in the 1940s and 1950s. In addi- 
tion, conclusive in vitro and in vivo studies have 
proven the effectiveness of topical fluoride applica- 
tion to the enamel surfaces of teeth in the reduction 
of dental caries. 

The use of fluorides has proven to be highly sig- 
nificant in the field of preventive dentistry. Most 
clinicians have certainly been exposed to the sys- 
temic and topical enamel applications of fluoride 
with resultant caries reduction. However, with the 
advent of highly sophisticated electron microscopic, 
electron diffraction, and microradiographic studies, 
research appears to be indicating additional benefi- 
cial results when this dental "panacea" is utilized in 
topical applications to exposed dentinal tubules, 
pulpal tissue, and cavity preparations. 

Response of Pulpal Tissues to 
Topically Applied Fluorides 

A review of the literature indicates that several 
earlier clinicians in the 1940s had considered the 
protective nature of fluorides when topically applied 
to dentin. Hoyt and Bibby (/) reported that the role 
of sodium fluoride had been established in its effi- 
cacy as a desensitizing agent for hypersensitive 
dentin. They observed clinically that this desensiti- 
zation took place in a very short time — a matter of 
three to five minutes. Because the mechanism of the 



desensitization was not understood at the time, 
several individuals began to clinically evaluate the 
results of topical fluoride applications to dentin. 
Studies by Barker (2), and Rovelstad and St. John (3) 
seemed to suggest that a lowered pulpal vitality was 
the probable means of desensitization. Because 
topical fluorides had been shown to remineralize 
enamel well, many believed that direct topical appli- 
cations of fluorides to dentin could possibly aid the 
remineralization of dentin — virgin or carious. There- 
fore, the maintenance of pulpal vitality became the 
dominant question with topical fluoride application 
to exposed dentinal surfaces. 

In 1949, Rovelstad and St. John (3) made a histo- 
logic study of the pulpal response to the application 
of NaF for five minutes to freshly cut dentin in 51 
young teeth. The conclusions they drew from the 
study were: (1) that indeed NaF would effectively 
desensitize freshly cut dentin in occlusal prepara- 
tions when applied topically; (2) histologic evidence 
proved there was a definite reaction of the young 
pulp in response to the irritation of the cutting of 
dentin. This reaction varied in severity according to 
the depth of the cutting; and (3) histologic evidence 
also proved the dental pulp is affected by the appli- 
cation of sodium fluoride to freshly cut dentin for a 
period of five minutes, in a manner differing from 
the reaction of the pulp to operative procedures. In 
all instances, they found the more severe pathologic 



IT McArthur is a staff member of the Dental Department, USS 
Canopus (AS-34), FPO New York 09501. This paper was written 
while he was in dental general practice residency. 



Volume 70, March 1979 



21 



condition associated with the five minute application 
of fluoride to dentin. The pulps in the area subtend- 
ing the cavity showed vacuolization of the odonto- 
blastic layer, leukocytic infiltration, hyperemia, and 
hemorrhage. As the time interval between treatment 
with fluoride and extraction increased from one hour 
to eight days, so did the severity of the pathologic 
condition of the pulp tissue. 

This was an excellent study with control speci- 
mens utilized for comparison. Critical comments are: 
(1) the authors did not mention the concentration of 
NaF solution utilized; {2) an air water spray was not 
utilized for cooling purposes during cavity prepara- 
tion; and (3) warmed gutta percha was utilized as a 
temporary filling material in the preps before the 
specimens were extracted. 

The results of a study by Maurice and Schour (4) 
in 1956, however, began to indicate that a relation- 
ship existed between the severity of the pulpal 
response and the concentration of the fluoride in 
solution. Their work was based on the histologic 
study of maxillary molar preparations in 54 albino 
rats to which various NaF concentrations of 1 %, 2%, 
4%, and 30% were incorporated into a bland zinc 
oxide filling paste known as Aquadont, The findings 
in the teeth fdled with the 1%, 2%, or 4% NaF or 
flooded with 4% NaF for five minutes were identical 
histologically to teeth filled with Aquadont alone. All 
of these specimens exhibited recovery after 32 days 
which was essentially complete with a reparative 
process consisting of a deposit of secondary dentin. 
In the teeth filled with Aquadont plus 30% NaF, 
severe alterations were observed and there was in- 
complete recovery and a greater deposition of 
secondary dentin. 

In another study, Perreault, Massler, and Schour 
(5) found the application of 4% NaF to cavities for 
five to ten minutes in rat incisors produced no appre- 
ciable histologic damage to the pulp. 

During the 1950s, sodium fluoride was the most 
frequently employed aqueous topical solution, but 
studies by Howell (6), Brudevold, et al (7), and 
Shannon and Hester (8) began to reveal that stan- 
nous fluoride offered a higher degree of protection 
and acid resistance. Many began to suspect the 
effects of SnF2 on the dentin and pulp. 

In 1967, two research articles were published. One 
by Massler and Evans (9), indicated that applica- 
tions of 10% SnF2 solutions to the freshly cut dentin 



of rat molars produced no immediate or long-term 
injurious reactions to the odontoblasts or pulp. This 
was true in shallow and in deep cavity preparations. 
This 10% SnF2 solution was applied for 30 seconds. 
They found no significant effects when they applied 
SnF2 directly to the pulp through small pulp expo- 
sures. All cavity preps were left exposed to the oral 
fluids without benefit of temporary filling materials 
before the rats were sacrificed at various time 
intervals. Interestingly enough, Massler and Evans 
found that the formation of bacterial plaques within 
the open dentinal cavities and the number of 
gram-positive streptococci within these plaques 
were significantly less in the fluoride-treated group 
than in the controls. 

The same year Weiss and Wei (10) also found very 
little, if any, inflammation in pulpal tissues in human 
teeth when an aqueous 10% SnF2 solution was 
applied to freshly prepared dentinal cavities in 
sound and carious lesions. No difference could be 
detected between the pulps of SnF2 treated carious 
teeth and control caries lesions. In fact, postopera- 
tive radiographs showed an increase in radiodensity 
of SnF2 treated carious teeth. 

Additional favorable reports were published. In 
1967, Andres, et al (11) reported no adverse pulpal 
effects after application of 10% and 30% SnF2 
solutions to deep cavity preparations in dog teeth. 
They even noted a decreased cellular response 
following the SnF2 treatment. 

In 1969, Weiss and Massler (12) completed an in 
vivo study of 87 young premolars to be removed for 
orthodontic reasons. Class V cavities were prepared 
and cotton pellets saturated with the following solu- 
tions were then sealed under fast setting ZOE 
cement for periods from one day to one month: SnF2 
10%, NaF 2%, acidulated fiuorophosphate 1.23%, 
distilled water, dry cotton pellets, and unoperated 
teeth were used as controls in contralateral teeth. 
Histologic examination showed no significant effects 
of any of these fluoride solutions on the underlying 
pulp, even when sealed into the cavity of one month. 
The cutting procedure itself, they noted, produced 
far more damage to the pulp under sharp line 
angles, especially when used dry, than did the fluo- 
ride solutions. The total or additive effect upon the 
pulp was considerably less than occurred under zinc 
phosphate and silicate cement fillings placed over 
one layer of copal resin varnish. 



22 



U.S. Navy Medicine 



Brannstrom and Nyborg (13) in 1971 completed a 
study and found their results were inconsistent with 
those of Weiss and Massler. Their in vivo study 
consisted of an histologic evaluation of 50 pairs of 
teeth divided into three groups in which buccal 
cavities were prepared. These deep buccal cavities 
were prepared with water cooling by a method that 
in the authors' earlier studies had been found not to 
produce appreciable damage of the pulp. Group I 
received an 8% SnF2 30- second application with a 
contralateral control tooth. Group II received an 8 % 
SnF2 5-minute application with a control. Group III 
received an 8% SnF2 5-minute application with the 
contralateral tooth receiving a 4% NaF 5-minute 
application. All cavities were filled with Pharmatec 
temporary filling material. All teeth were extracted 
after one week. 

Histologic results indicated the thickness of the 
cavity floor in these teeth ranged from 0.07 to 0.20 
mm. In Group II, a pulpal response of moderate in- 
flammation to pulpal necrosis could be elicited. All 
other teeth with SnF2 and NaF applications and con- 
trols did not exhibit any inflammatory changes. They 
suggest the reason for the discrepant results 
between SnF2 and NaF may lie in the fluoride ion 
concentration which is about Five times greater in 
8% SnF2 than in 4% NaF. A contributing reason for 
the damage may be the acidity of the 8% SnF2 
(pH2.6). However, earlier research indicates no local 
necrosis of the effect of acid cement on the pulp. 
Finally, Furseth and Mjor (14) in 1973 observed that 
a 2-minute application of 2% NaF in prepared 
cavities just prior to restoration had no adverse 
effect on the pulp. 

These studies indicate that fluoride applied 
topically to cavity preparations in moderate concen- 
trations for short periods of time is not harmful to the 
pulpal tissues, but caution should be exercised when 
high concentrations are used for long periods. 



Effects of Topical Fluorides on Dentin 

Much has been written on fluoride's beneficial 
effects on enamel solubility resistance. However, 
since dentin and enamel differ markedly in then- 
organic and inorganic composition, the mechanism 
by which fluorides reduce dentin solubility would be 
expected to be different than in enamel. 



Buonocore (1961) (15) found that the rate of dis- 
solution of enamel in various acids was dependent on 
the kind of acid used, while the rate of dentin dis- 
solution was pH dependent. Dentin dissolves faster 
than enamel at a pH of 5.5, while the order is 
reversed at pH 3.5. If the organic matter is removed 
prior to decalcification, dentin dissolves faster than 
enamel, regardless of the pH. 

In 1967, Wet and Massler (16) investigated the 
effect of 2% sodium and 10% SnF2 solutions on 
carious dentin, using radiographic and electron 
microscope techniques. Radiographs of SnF2-treated 
carious dentin showed a great increase in radiopacity 
compared with radiopacity before treatment. Radio- 
density increased with time of immersion. No signifi- 
cant difference was seen between the electron micro- 
graphs of sections treated with NaF and of untreated 
sections of active carious lesions. The sections with 
SnF2 showed an electron-dense granular material 
that was deposited within the dentinal matrix and 
was especially dense in the peritubular zone. This 
indicates a remineralization that may have occurred 
as a result of chemical reaction between the residual 
hydroxyapatite in carious dentin and SnF2. 

Wei, Kaqueler, and Massler (17) confirmed in 
their study in 1968 the hypothesis that demineralized 
carious dentin may be remineralized in vitro. Based 
on radiographic and rnicroradiographic evidence, a 
10% SnF2 solution appeared to remineralize carious 
dentin more rapidly than, and was superior to, other 
remineralizing solutions and calcifying solutions. 
Reduced straining of carious dentin with toluidine 
blue and orange G indicated increased resistance to 
dye penetration. Deposition of finely granular, 
electron- dense material in the dentinal matrix was 
seen with electron microscope. Also in 1968 Selvig 
(18) demonstrated that prepared dentin surfaces, 
treated with a 2% NaF solution, would reduce the 
acid solubility of both zones, but that the 
intertubular zone was now more readily dissolvable 
than the peritubular zone. He concluded the pene- 
tration of fluoride was primarily along the dentinal 
tubules. He further concluded that since current 
concepts of caries held its progress was primarily 
along the tubules, any treatment of normal dentin 
that would increase the resistance of the peritubular 
zone and the mineralized content of the tubules to 
dissolution by bacterial acids would, conceivably, 
retard the caries process. 



Volume 70, March 1979 



23 



Fluoride Effects on Recurrent Decay 

With the results of Selvig's study in print, numer- 
ous investigators began to report a reduction in re- 
current caries in humans and experimental animals 
following topical fluoride application. 

Gross, Goldberg, and Loiselle (19) in a study 
involving topical fluoride application to Class V 
cavity preps in hamsters, discovered a 50% reduc- 
tion in the occurrence of caries at the margin of the 
restorations in the fluoride-treated group as com- 
pared to the untreated control group. 

Alexander, McDonald, Stookey (20) in 1969 re- 
ported a study in which they evaluated the effective- 
ness of a stable 30% SnF2 solution on recurrent 
caries around the margins of amalgam restorations 
in 34 children. Children receiving the SnF2 treat- 
ment experienced a 58.9% reduction in recurrent 
caries when compared to the control children. The 
children receiving the SnF2 treatment showed a 
60.7% and 46.7% reduction in recurrent caries in 
permanent and deciduous teeth respectively, when 
compared to the control children. This reduction in 
recurrent caries was attributed to the anticariogenic 
effect of the SnF2 treatment. Recurrent caries 
around the margins of restorations appeared to 
depend on (1) the caries susceptibility of the 
adjacent tooth structure, (2) the extension of the 
cavity preparation, and (3) the condition of the 
amalgam-enamel margins. 

Stannous Fluoride as an Indirect 
Pulp-Capping Material 

Nordstrom, et al (21) in 1974, compared a 10% 
SnF2 solution to the more conventional Ca(OH)2 
preparation in indirect pulp capping procedures in 
human deciduous and permanent teeth. The 10% 
SnF2 treatment was applied for five minutes. The 
treatment period was 94 days. They found no signifi- 
cant difference between the failure rates of teeth 
treated by both means, (i.e. both were effective). 
However, the use of the SnF2 had one advantage. 
That being, teeth treated with SnF2 showed harder 
remineralized dentin and greater radiodensity than 
teeth treated with Ca(OH)2. This evidence supports 
the hypothesis that SnF2 produces remineralization 
of demineralized dentin in vivo. Stannous fluoride 
may react with residual hydroxyapatite in the 



demineralized dentin to form Sn 3 F 3 P0 4 . This study 
shows conclusively that SnF2 is a good agent to use 
for indirect pulp capping procedures in that the 
vitality of the pulp is maintained, the carious process 
is arrested, remineralization of the demineralized 
dentin is promoted, and secondary dentin formation 
is stimulated. 

Discussion 

The dental profession has overwhelmingly ac- 
cepted the utilization of fluorides for systemic and 
topical application for increased caries resistance of 
the enamel layer. However, for several decades, the 
profession has, in general, been reluctant to utilize 
topical fluorides on exposed dentinal and pulpal 
tissues due to the fear that topical fluorides would 
severely damage dentinal and pulpal tissues leading 
to the early demise and devitalization of teeth. In 
addition, although the profession could accept that 
fluorides could increase surface enamel reminerali- 
zation, there were questions as to whether dentin 
would respond in the same fashion. Also, the prac- 
tice of treating cavity preparations with aqueous 
fluorides prior to restoration has never been popular 
because of the time involved, as in the case of freshly 
mixing the solutions, and the expense. 

Just as freshly erupted enamel is highly suscepti- 
ble to caries, since it lacks the fluoride-rich protec- 
tive layer that forms following exposure to oral fluids 
(Massler 1968) (22), so does freshly cut enamel and 
dentin of cavity preparations. Marginal leakage 
around dental restorations allows for bacteria and 
their toxic products to come in contact with these 
exposed susceptible surfaces to produce recurrent 
decay. Any safe means of reducing the dissolution of 
the susceptible surfaces would be most beneficial. 

Conclusions 

The literature presented here supports: 
(1) that, aqueous topical fluorides applied to 
cavity preparation do not cause an irreversible 
pulpitis with subsequent necrosis of the pulp when 
moderate concentrations (10% or less) are applied to 
the preparation for short periods of time (less than 
five minutes). However, caution should be exercised 
when high concentrations are used for longer 
periods. Also, the preponderance of literature 



24 



U.S. Navy Medicine 



suggests that topical fluorides are not irreversibly 
irritating to the pulp if applied over dentin, however, 
the effect of topical fluoride over an exposure is not 
completely known. Therefore, the clinician should 
avoid topical application to dentin where there is any 
likelihood of exposure. 

(2) that, topical fluorides particularly SnF2 as 
opposed to NaF when applied to cavity preparations 
has a beneficial effect upon the dentin in that, 
carious and virgin dentin is remineralized with a 
resultant decrease in acid solubility. Conceivably, 
this infers that the caries process should therefore be 
retarded in dentin. ' 

(3) that, topical fluorides applied to cavity prep- 
arations before alloy or prosthetic placement does 
significantly reduce recurrent caries around the 
margins of the restoration. 

(4) that SnF2 can be utilized as an effective in- 
direct pulp capping material with greater radioden- 
sity and harder remineralized dentin when compared 
to Ca(OH)2 without pulpal devitalization. 

The literature appears to suggest that SnF2 is the 
topical fluoride of choice. Of course much research 
continues in this field. Shannon (23) has contributed 
significantly to this area of dentistry. He has shown 
with numerous studies that smaller concentrations of 
fluorides (0.4%), in particular with SnF2, are really 
all that is needed to produce beneficial results, i.e. 
enamel and dentin solubility reduction by acids. 
Indeed his group has developed stable gel forms of 
fluorides for topical application to increase the shelf- 
life and the ease of utilization of fluorides, and to 
decrease their expense. 

The dental profession is strongly encouraged to 
re-evaluate these beneficial effects of topical fluo- 
rides to cavity preparations. The literature demon- 
strates that the fears and concerns of the dental pro- 
fession are unfounded scientifically with regard to 
the use of fluorides on dentinal and pulpal tissues. 
Therefore, our patients could and should be receiv- 
ing topical fluoride applications on cavity preps 
during restorative treatment to derive the benefits 
enumerated above in attempts to reduce the 
potential and incidence of recurrent decay. 

References 

1. Hoyt WH, Bibby BG: Use of sodium fluoride for desensitiz- 
ing dentin. JADA 30:1372-1376, 1943. 



2. Barker JN: Reactions of the pulp to various filling materials 
and clinical procedures. Aust J Dent 46:226, 1942. 

3. Rovelstad GH, St. John WE: Condition of the young dental 
pulp after the application of sodium fluoride to freshly cut dentin. 
JADA 39:670, 1949. 

4. Maurice CG, Schour 1: Effects of sodium fluoride upon the 
pulp of the rat molar. J Dent Res 35:69-82, 1956. 

5. Perreault JG, Massler M, Schour I: Reaction of odonto- 
blasts to medicaments placed in cavity preparations in rat inci- 
sors. JADA 52:533-554, 1956. 

6. Howell CL, Gish CW, Smiley RD, Muhler JC: Effect of 
topically applied stannous fluoride on dental caries experience in 
children. JADA 50:14, 1955. 

7. Brudevold F, Steadman LT, Gardner DE, Rowley J, Little 
MF: Uptake of tin and fluoride by intact enamel. JADA 53:159, 
1956. 

8. Shannon IL, Hester WR: Effect of aqueous stannous fluo- 
ride on enamel solubility. J South Calif St Dent Assoc 30:302, 
1962. 

9. Massler M, Evans JA: Absence of pulpal response to 
stannous fluoride applied to freshly cut dentin. J Den Res 46: 
1469, 1967. 

10. Weiss MB, Wei SHY: Pulpal response to stannous fluoride 
applications. LADR Program and Abstracts of Papers, No. 574, 
1967. 

11. Andres CJ, Stookey GK, Muhler JC: Studies concerning 
the effect on the dental pulp in dogs of a stable stannous fluoride 
solution applied to freshly cut dentin. J Oral Ther Pharm 4:113, 
1967. 

12. Weiss MB. Massler M: Pulp reactions to fluorides. 1ADR 
Program and Abstracts of Papers, No. 663, 1969. 

13. Brannstorm M, Nyborg H: Pulp reaction to fluoride solu- 
tion applied to deep cavities: an experimental histological study. J 
Dent Res 50:1548, 1971. 

14. Furseth R, Mjor IA: Pulp studies after 2% NaF treatment 
of experimentally prepared cavities. Oral Surgery 36:109, July 
1973. 

15. Buonocore MG: Dissolution rates of enamel and dentin in 
acid buffers. J Dent Res 40:561, 1961. 

16. Wei SHY, Massler M: Fluoride applications to carious 
dentin. J Dent Res 46:1110, 1967. 

17. Wei SHY, Kaqueler JC, Massler M: Rernineralization of 
decayed dentin. J Dent Res 47:381, 1968. 

18. SelvigKA: Effect of fluoride on the acid solubility of human 
dentin. Arch Oral Biol 13:1297, 1968. 

19. Gross RL, Goldberg F, Loiselle RJ: Reduction of carious 
lesions at the margin of restorations. 1ADR Program and Ab- 
stracts of Papers, No. 126, 1969. 

20. Alexander WE, McDonald RE, Stookey GK: Effect of a 
stable 30% stannous fluoride solution on recurrent caries around 
amalgam restorations. IADR Program and Abstracts of Papers, 
No. 547, 1969. 

21. Nordstrom DO, Wei SHY, Johnson R: Use of stannous 
fluoride for indirect pulp capping. JADA 88:997. 1974. 

22. Massler M: Changing concepts in prevention and treat- 
ment of dental caries. J Tenn Dent Assoc 48:109, 1968. 

23. Shannon IL: Water-free solutions of stannous fluoride and 
their incorporation into a gel for topical application. Car Res 
3:339, 1969. 



Volume 70, March 1979 



2!) 



Nutrition: New Component in 
Patient Education 



LT Wendy L Harrison, MSC, USN 



As current medical attention focuses on preven- 
tive health care to counteract disease and minimize 
treatment, interest in nutrition soars. Studies point 
to both over- and under-nutrition as risk factors in 
disease development {7,9,12,14,22), with conse- 
quent government sponsorship of nutrition pro- 
grams {1,4,5,11) and interest in a National Nutrition 
Policy (2,6,18). Increasingly, physicians are looking 
for ways to blend the physical properties of food 
metabolism with the social sciences to yield con- 
sistent dietary changes. Yet one almost unrecog- 
nized source of existing government funding for 
nutrition education is the military dietitian. The mili- 
tary dietitian serves clientele who usually have an 
adequate food supply, represent various geographic 
backgrounds, and are frequently centralized in base 
housing, facilitating dissemination of nutrition infor- 
mation to the wife or family "gatekeeper (16)." 

To pinpoint naval dietetic services, a question- 
naire was mailed to each of the 31 registered 
dietitians on the "Hospital Food Service Program 
Officers" roster (S). Those invited represented 20 
naval installations and a population which was 71% 
female and 29% male. Thirteen percent were listed 
as ensigns, 22% as junior grade lieutenants, 55% as 
full lieutenants, and 10% as lieutenant commanders 
or above. Eleven persons were shown to work either 
as the sole dietitian or in a joint Food Service 
Officer/Registered Dietitian billet. 

Results 

Of those invited, 17 (54%) returned the completed 
questionnaire and two unsolicited responses were 
received from civilian dietitians also working at 
naval facilities. The average length of naval service 
per respondent (civilian excluded) was 6.9 years with 



LT Harrison is a clinical dietitian at NRMC Great Lakes, 111. 

60088. 



a range from three to IS'/j years; some responses in- 
clude Navy-sponsored school or enlisted service. 
Several internships and geographic locations were 
represented, along with five persons educated at 
Ohio State University under the Naval Enlisted 
Dietetic Education Program (NEDEP). College 
majors concentrated on the nutritional sciences and 
general dietetics versus food service administration 
or business. In addition, 31% of the respondents 
have a master's degree and 21% are currently 
pursuing a graduate diploma. 

Ninety-five percent (18) of the responding facili- 
ties have a "Nutrition Clinic" for outpatient care and 
67% of these require appointments. A physician's 
consultation request is required by 83% of the 
respondents although some staff, walk-in, and 
weight reduction patients are excepted. The majority 
of dietitians spend 15 minutes to an hour on initial 
instructions depending upon the type of diet and 
whether an individualized or preprinted form is 
used. The nutritionist's perception of patient 
motivation also undoubtedly affects length of in- 
struction as half the respondents felt only one in four 
patients requests dietary advice. Routine nutritional 
follow-up is provided by 53% of the dietitians with 
an average return rate among weight reduction pa- 
tients of 80%. The impetus for this return may be 
the current stress upon weight reduction by the 
Armed Forces (13). 

All respondents use the American Diabetes Asso- 
ciation's "Exchange Lists" (3,10) for their weight 
reduction and diabetic patients. Twenty-six percent 
have changed to the new system, featuring fat modi- 
fications, and most anticipate conversion within the 
next year. Two respondents stated they plan to im- 
plement the new system for diabetics, but find it too 
confusing for weight reduction. Exercise, in the form 
of measured walking, aerobics, and behavior modifi- 
cation, is routinely discussed in relation to obesity, 
but only mentioned by 21% of the respondents to 
diabetics. The educational techniques are supple- 



26 



U.S. Navy Medicine 



mented by anthropometric measurements, most 
notably height (84%) and weight (95%). Rarely are 
any other measurements taken directly by the nutri- 
tionist, although one respondent reported routine 
referral of hypertensive patients for blood pressure 
checks and is hoping to incorporate this measure- 
ment into usual nutrition statistics, Ten dietitians 
indicated they customarily discuss laboratory values 
with their patients, 26% speak of urine testing, and 
one briefs on dietary preparation for blood work. 

Half the respondents make referrals to other 
clinics within their facilities and 32% report sending 
patients to community agencies such as the Diabetes 
Association, Weight Watchers, and Overeaters 
Anonymous. Further community resources include 
Alcoholics Anonymous, ALAnon, the Cancer Soci- 
ety, County Board of Health, Food Stamp Program, 
Heart Association, Navy Relief, Public Health Nutri- 
tionists, TOPs (Take Off Pounds Sensibly), and WIC 
(Supplemental Feeding Program for Women, In- 
fants, and Children). Fifty-three percent of the dieti- 
tians are also part of prenatal programs either 
through individual consultation, prepared parent- 
hood classes, or other weekly group sessions. Most 
respondents (68% have advertised their nutrition 
services in base newspapers and one person regular- 
ly writes nutrition articles. Approximately half the 
respondents conduct general nutrition education to 
base organizations, including aeronautical attach- 
ments and ship crews. Community liaison is main- 
tained through volunteered services to off base 



scouting troops, churches, schools, clubs, and local 
dietetic organizations. 

Inpatients are usually seen as a result of the Physi- 
cian Consultation Request Form (SF 513) as only 
16% of respondents routinely accompany the physi- 
cians on ward rounds. However, one respondent 
works as part of a nutritional assessment team in- 
volving total parenteral nutrition and four others 
serve on patient care audit committees. Although no 
individual facilities have professional standards 
review of nutrition services, response to establishing 
Navywide criteria was favored by 75 % of the partici- 
pants. Dietitians subjective assessment of working 
relationships with other departments are shown in 
Table I. One respondent additionally listed the psy- 
chology department as an area with which good 
liaison is maintained. 

Discussion 

The variety of nutrition areas pursued by the re- 
sponding dietitians reflect awareness of their 
changing role within the medical spectrum. No 
longer confined to a small basement office circling 
menus, they serve as adjuncts to other health care 
practitioners and as patient educators. Because of 
this new role as "fact interpreter," dietitians rec- 
ognize the need for more individualized instruction 
time, organized follow-up, and active involvement of 
the patient in his own care. All of these factors make 
the last-minute-diet-consult and the "stop by and 



TABLE 1. 


Dietitian Working Relationships with Other Medical Services 






Poor 


Fair 


Average 


Very Good 


Excellent 


Never Deal 
With 


Laboratory 





1 


4 


5 


2 


7 


Radiation Therapy 





1 


4 


2 


1 


11 


Pharmacy 








2 


9 


7 


1 


Data Processing 








5 


5 


2 


7 


Physical Therapy 








1 


7 


7 


4 


Occupational Therapy 








1 


4 





13 


Nursing Service 








3 


10 


6 





Medical Officers 








6 


8 


5 





Surgical Officers 








7 


7 


3 


2 


Red Cross 








5 


3 


5 


6 


Local Civilian Dietitians 








3 


7 


3 


6 



Volume 70, March 1979 



27 



just pick up a diet" approach of some health practi- 
tioners outmoded and naive. As Kaufman points out, 
"... dietary treatment is introduced to many pa- 
tients in the form of a perfunctory statement or 
printed meal plan that bears little or no resemblance 
to their life-long pattern of eating (20)." As several 
studies indicate (15,21,23,24,25,26), the time hon- 
ored Exchange Lists, basis for nearly every drug 
company diet handout, are difficult for patients to 
comprehend without instruction. Verifying this, 
Holland found a higher proportion of diabetics fol- 
lowing their diet when instructed in its use. She con- 
cludes the results implicate the instructor-patient 
relationship as an important factor in motivating the 
diabetic patient to adhere to nutritional suggestions 
(19). Ginther further suggests that many disappoint- 
ing actions on the part of patients may be ". . . hon- 
est and innocent actions taken on the basis of misun- 
derstandings, revealing incomplete concepts (17)." 
Certainly motivation is a factor in diet change, but no 
patient should be unsuccessful simply because of 
"incomplete concepts." The naval dietitians re- 
sponding to the survey appear to be trying to im- 
prove their quality of inpatient care while also reach- 
ing the naval community at large with preventive 
nutrition and developing more precise tools for 
accomplishing these tasks. Rather than asking pa- 
tients how they like their meat cooked, professional 
time now targets on teaching the patient how to cook 
his food at home, educating him as to his diet's 
rationale, and developing materials to do so effi- 
ciently. Use of auxiliary personnel, such as dietitic 
assistants and technicians* to facilitate inpatient 
care may prove more cost- and patient-effective in 
routine hospital kitchen management. Dietitian time 
is then freed for patient education, exploration of 
community supplementary resources, and increased 
continuity of nutritional care. 



Summary 

A survey was conducted among the active duty 
dietitians in the United States Navy. Results indicate 
many have graduate degrees and are taking expand- 
ing roles in the medical setting. Future studies 



♦Dietetic Assistant: One year post- high school curriculum with 

examination. Approved by American Dietetic Association. 
Dietetic Technician: Two year program leading to associate de- 
degree from junior college. Approved by American Dietetic 
Association. 



should include data from civilian dietitians in naval 
facilities and also monitor the efficiency of adjunc- 
tive food service personnel in routine patient care. 

References 

1. Congressional Declaration of Purpose. Child Nutrition Act 
of 1966. 42nd Congress, No. 1771, 1966. 

2. Dietary Goals for the United States. Senate Select Com- 
mittee on Nutrition and Human Needs. Nutrition Today 12(5):20, 
1977. 

3. Exchange Lists for Meal Planning. Amer Diab Assoc, Inc., 
New York, 1976. 

4. Food Stamp Program. US Dept of Ag Food and Nutr Ser- 
vice. Wash., D.C. 20250. 

5. Four views of WIC: a unique environment for nutrition 
education. J Nutr Ed 8(4): 156, 1976. 

6. Guidelines for a National Nutrition Policy. Nat Nutr Con- 
sortium, in Food Tech 28(7):20, 1974. 

7. Highlights: Ten States Nutrition Survey. USDHEW. Center 
for Disease Control, Atlanta, 1973. 

8. Hospital Food Service Program Officers, Bureau of Medi- 
cine and Surgery. U.S. Navy, Wash., D.C, 1976, 

9. Maternal Nutrition and the Course of Pregnancy. National 
Academy of Science-National Research Council. Wash., D.C., 
1970. 

10. Meal Planning with Exchange Lists. Amer Diab Assoc, 
Inc., New York, 1950. 

11 . Nutrition Program for the Elderly. Fed Reg 37(162):Part II, 
1972. 

12. Principles of Nutrition and Dietary Recommendations for 
Patients with Diabetes Mellitus: 1971. Diabetes 20(9):633, 1971. 

13. Weight Control BUPERSINST 6110.28, Bureau of Naval 
Personnel and Bureau Medicine and Surgery. U.S. Navy, Wash,, 
D.C, 1976. 

14. Blackburn GL, etal: Nutrition and metabolic assessment of 
hospitalized patients. JPEN 1(1):11, 1977. 

15. Etzwiter DD: Juvenile diabetes and its management: 
family, social, and academic implications. JAMA 181:304, 1962. 

16. Gifft HH, et al: Nutrition, Behavior and Change. Prentice 
Hall, Inc. Englewood Cliffs, p 33, 1972. 

17. Ginther JR: Educational diagnosis of patients. J Amer Diet 
Assoc 59:560, 1971. 

18. Hegsted DM: Food and nutrition policy — now and in the 
future. J Amer Diet Assoc 64(4):367, 1974. 

19. Holland WM: The diabetes supplement of the national 
health survey III: the patient reports on his diet. J Amer Diet 
Assoc 52:391, 1968. 

20. Kaufman M: The many dimensions of diet counseling for 
diabetes. Amer J Clin Nutr 15:45, 1964. 

21. Mills JW, et al: Socioeconomic problems on insulin 
dependent diabetes. Med J Aust 2:1040, 1973. 

22. Mueller JF: A dietary approach to coronary artery disease, 
J Amer Diet Assoc 62{6):613, 1973. 

23. Nickerson D: Teaching the hospitalized diabetic. Amer J 
Nursing 72(5):935, 1972. 

24. Ohlson MA: Suggestions for research to strengthen learn- 
ing by patients. J Amer Diet Assoc 52:401, 1968. 

25. Power L: Commentary: new approaches to the old problem 
of diabetes education. J Nutr Ed 5(4):230, 1973. 

26. Williams TF, et al: Dietary errors made at home by patients 
with diabetes. J Amer Diet Assoc 51:19, 1967. 



28 



U.S. Navy Medicine 



BUMED SITREP 



NATIONAL ALCOHOLISM FORUM ... The Annual 
Conference of the National Council on Alcoholism 
will be held at the Sheraton Park Hotel in Washing- 
ton, D.C. Beginning on 27 April 1979 and continuing 
through 2 May 1979, the Conference will feature 
speakers and paper presentations from throughout 
North America. The advanced registration deadline 
is 6 April 1979. Additional information can be ob- 
tained by writing Forum Coordinator, National 
Council on Alcoholism, Inc., 733 Third Avenue, 
Suite 1405, New York, N.Y. 10017. 



BIOMEDICAL RESEARCH PROJECTIONS . . . 

With the turn of the century only 20 years distant, 
the Naval Medical Research and Development Com- 
mand has projected several major breakthroughs in 
biomedical research will occur by 1999 due to current 
Navy programs. 
They include: 

1. Development of a single injection malaria vac- 
cine that will give complete sustained protection to 
combat forces. 

2. Development of a single agent defense against 
multiple mission aborting virus illnesses (Inter- 
feron). 

3. Development of cheap, readily available artifi- 
cial blood to completely eliminate need for blood 
banking in combat areas. 

4. Vaccine against dental caries organisms to 
eliminate need for dental profession except for cos- 
metic and reconstructive surgery. 

5. Protective strategies against genetic engineer- 
ing leading to development of alien biological war- 
fare agents. 

6. Genetic manipulation leading to elimination of 
genetic diseases such as sickle cell anemia. 

7. Development of an immediate response infec- 
tious disease diagnosis capability. 

8. Development of accurate, quantitative predic- 
tion models for: 

Impact injury 

World-wide infectious disease 

Cold injury 

Role of low level multi-environmental hazards in 



causing and aggravating diseases of long latent 
periods. 

9. Development of a casualty evacuation system 
that does not require skilled physician participation 
until delivery to tertiary health care eschelon. (By 
use of a dedicated communications network.) 

10. Pharmacological repair of noise related hear- 
ing damage. 



CHAMPUS HANDBOOK BEING DISTRIBUTED 
... A mass printing of the CHAMPUS Handbook for 
Beneficiaries has been completed and the initial 
steps have been taken to place it in Service distribu- 
tion channels, according to DOD officials. 

The officials note that it will be several weeks be- 
fore the 92-page booklet will be available through 
CHAMPUS Advisors/Health Benefits Advisors, 
CHAMPUS Contractors, and OCHAMPUS. They 
add that copies are being mailed to retiree families. 

The handbook summarizes who is eligible for 
CHAMPUS benefits, the extent of benefits, circum- 
stances under which the benefits are available, how 
to claim benefits, and other pertinent information 
about the entire program, 

A limited quantity of the publication was distrib- 
uted last summer to selected individuals who were 
asked to evaluate its readability and content. 
CHAMPUS officials anticipate that every family 
which is eligible for the program will receive a copy 
of the current printing. 



DIABETIC NEUROPATHY PAMPHLETS AVAIL- 
ABLE . . . Navy Medical Department personnel can 
order a new pamphlet, "The Diabetic Neuropathies: 
A Scientific Guide for Health Practitioners," free of 
charge from the National Institute of Neurological 
and Communicative Disorders and Stroke (NINCDS). 
The pamphlet describes the four major types of dia- 
betic neuropathy and summarizes current treatment 
methods. Write the Office of Scientific and Health 
Reports, NINCDS, National Institutes of Health, 
Bethesda, Md. 20014. 



Volume 70, March 1979 



-MJ.S, GOVERNMENT PRINTING OFFICE:! 9 7 9 2 81 <* 7 1 1 



U.S. NAVAL PUBLICATIONS and FORMS CENTER 
ATTN: CODE 306 
5801 Tabor Avenue 
Philadelphia, Pa. 19120 



POSTAGE AND FEES PAID 

DEPARTMENT OF THE NAVY 

OoQ-316 




Official Business 



CONTROLLED CIRCULATION RATE 



SUBSCRIPTIONS AVAILABLE 



U.S. NAVY MEDICINE is now available by sub- 
scription. Supporters of Navy medicine who are not 
eligible for free distribution, or who want their copy 
sent to their home address may order a personal 



subscription through the U.S. Government Printing 
Office. Subscription rates are Sll per year (12 is- 
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